Lawmakers in Tennessee recently revived a bill that would allow certified anesthesiologist assistants to practice in the state in an effort to address the ongoing anesthesia provider shortage.

The bill would allow CAAs to practice in the state, where they currently need additional state approval. There are currently 21 states that allow CAAs to practice without state approval and at a similar level of independence to CRNAs, but all CAAs must still practice under the direction of a physician.

The bill has brought Tennessee into the center of the conversation around strategies for addressing the shortage and how to best regulate anesthesia care team structures to expand care coverage while maintaining patient safety and saving healthcare costs.

The factors behind Tennessee’s anesthesia shortage

“Many factors play into this demand, such as an aging patient population, growth in the number of non-surgical procedures requiring anesthesia, an increase in the number of outpatient surgery centers and a decrease in post-COVID medical providers,” Kelli Ray, a certified anesthesiologist assistant and president of the Tennessee Academy of Anesthesiologist Assistants, told Becker’s.

She also said that many of the open positions for certified registered nurse anesthetists, who are also a crucial part of anesthesia care teams, are often filled by traveling CRNA providers from out of state, which can be expensive.

The Tennessee Society of Anesthesiologists echoed these sentiments, and said that every metro area in the state is facing a shortage of anesthesia professionals, with CRNA vacancy rates in some practices exceeding 20%.

Cuts to reimbursements for anesthesia have also put a strain on the supply side of the provider equation in Tennessee and across the country. CMS anesthesia reimbursements have also declined 8.2% from 2019 to 2024 — from $22.27 per unit to $20.44, according to a May blog post by VMG Health.

Anesthesiologist, anesthesiologist assistant and CRNA organizations in the state all pointed to the shortage of residency slots in anesthesia as being a primary factor in the shortage. In 2024, 1,695 anesthesiology residency positions were available nationwide, and around 44% of medical students seeking an anesthesiology residency did not match.

Proposed strategies and solutions 

“Many steps could help to alleviate this shortage of anesthesia professionals in Tennessee, including increasing the number of anesthesiologist residency training positions, expansion of rural pass-through to include anesthesiologists, and increasing the number of student nurse anesthetist positions in Tennessee nursing schools with a focus on retaining those students to work as CRNAs in our state after graduation,” said Ronald Harter, MD, president of the American Society of Anesthesiologists, in a statement shared with Becker’s.

ASA and TSA also expressed support for a Tennessee bill that would provide licensure to CAAs in the state’s last legislative session in statements shared with Becker’s.

Others have expressed concern that because CAAs must still practice under an anesthesiologist, the bill would not do enough to adequately expand coverage in rural areas.

In a report published by WKRN, Chris Hulin, DNP, CRNA, the president of the Middle Tennessee School of Anesthesia, which trains CRNAs, said that CAA use would “lock in” an expensive care model.

“They can do no patient care without a physician anesthesiologist being present in a ratio of 1 to 4, so every time you have a patient encounter, you’re paying two people,” Mr. Hulin said.

But others argue that allowing state certification of CAAs would still make a significant difference in the availability of anesthesia providers, as anesthesia is in high demand for an increasing number of procedures, not just surgeries.

“There are 3,800 certified anesthesiologist assistants currently practicing in 20 states across the country. Many of these CAAs are originally from Tennessee, have family in Tennessee, or would love to live and work in Tennessee,” said Ms. Ray of TAAA. “We are highly skilled anesthesia providers with the desire to care for patients in Tennessee, just like we do in the nearby states of Georgia, Florida, Alabama, North Carolina and South Carolina.”

“We are asking for Tennessee lawmakers to give hospitals the option to work with both types of advanced practice anesthesia providers as well, just as they do for other medical specialities,” she continued. She also supports adding an accredited CAA school in Tennessee to immediately address the shortage.

Between 2022 and 2023, prescriptions for GLP-1 drugs soared 132.6% while bariatric surgery rates fell 25.6%, according to a new study from researchers at Boston-based Harvard Medical School and Brigham and Women’s Hospital.

The findings offer a clearer picture of how the growing popularity of GLP-1 weight loss drugs is affecting demand for bariatric surgeries, which have long been the gold standard treatments for weight loss.

“Our study provides one of the first national estimates of the decline in utilization of bariatric metabolic surgery among privately insured patients corresponding to the rising use of blockbuster GLP-1 RA drugs,” Thomas Tsai, MD, senior study author and a metabolic bariatric surgeon at Boston-based Brigham and Women’s Hospital, said in a news release.

The study was published Oct. 25 in JAMA Network Open and is based on a national sample of insurance claims data from more than 17 million privately insured adults. Using the data set, researchers identified patients with an obesity diagnosis who did not have diabetes in 2022 and 2023, and compared the portion of patients who were prescribed GLP-1 medications to those who underwent metabolic bariatric surgery.

Among the patients with obesity, nearly 95% did not receive either form of treatment, underscoring widespread access challenges, researchers said.

The findings add empirical evidence to a trend surgeons began calling attention to early this year. In March, several bariatric surgeons told Becker’s referrals were decreasing. In June, Vizient released a report that estimated inpatient bariatric surgery rates will drop 15% by 2034 due to more weight loss drugs entering the market and outpatient surgery volumes increasing.

In terms of cost comparisons, several studies suggest bariatric surgeries may be more cost effective in the long run, despite their upfront cost of between $15,000 and $23,000.

CMS released its 2025 physician payment rule, which includes a 94 cent (2.83%) conversion factor decrease from 2024.

The physician fee schedule conversion factor for 2025 is $32.35, down from $33.29 in 2024, according to a Nov. 1 CMS news release.

The final rule was met with criticism by the American Medical Association and the Medical Group Management Association.

“To put it bluntly, Medicare plans to pay us less while costs go up,” AMA President Bruce Scott, MD, said in a Nov. 1 statement. “You don’t have to be an economist to know that is an unsustainable trend, though one that has been going on for decades. For physician practices operating on small margins already, this means it is harder to acquire new equipment, harder to retain staff, harder to take on new Medicare patients, and harder to keep the doors open, particularly in rural and underserved areas.”

MGMA Senior Vice President of Government Affairs Anders Gilberg said in a Nov. 1 statement that CMS and Congress “have once again overlooked the sobering financial realities facing our nation’s medical practice.”

“Today’s final rule throws the financial viability of physician practices into question and threatens beneficiary access to care,” he said.

Both organizations are calling on Congress to pass a recently introduced House bill that would stop the cuts that are scheduled to go into effect Jan. 1. Rep. Jimmy Panetta of California said the legislation would not only prevent cuts, but would adjust provider reimbursements for inflation.