Chairman Michaud, Ranking Member Miller, and Members of the Subcommittee:

The American Association of Nurse Anesthetists (AANA) is the professional association that represents over 39,000 Certified Registered Nurse Anesthetists (CRNAs) across the United States. Over 500 CRNAs are employed by the Department of Veterans Affairs (DVA) healthcare system.   We appreciate the opportunity to present our testimony to the Subcommittee.  With our military personnel and Veterans’ access to safe and high quality healthcare our first priority, we want you to know that the profession of nurse anesthesia is working creatively and effectively with the Department of Veterans’ Affairs (DVA), in partnership with the U.S. Army, to improve its retention and recruitment of CRNAs, so that high quality anesthesia services remain available and accessible for our nation’s Veterans.  This work is crucial for several reasons; most importantly, because the anesthesia workforce needs in the DVA are increasing.  Our request of the Committee is to understand these needs and to examine more closely the VA anesthesia workforce to ensure the safest, most cost-effective anesthesia services for our Veterans.

CRNAs AND THE VA:  A TRADITION OF SERVICE

Let us begin by describing the profession of nurse anesthesia, and its history and role with the Veterans Administration health system.

In the administration of anesthesia, CRNAs perform the same functions as anesthesiologists and work in every setting in which anesthesia is delivered including hospital surgical suites and obstetrical delivery rooms, ambulatory surgical centers, health maintenance organizations, and the offices of dentists, podiatrists, ophthalmologists, and plastic surgeons.  Today, CRNAs administer some 30 million anesthetics given to patients each year in the United States.  Nurse anesthetists are also the sole anesthesia providers in the vast majority of rural hospitals, assuring access to surgical, obstetrical and other healthcare services for millions of rural Americans. 

Since the mid-19th Century, our profession of nurse anesthesia has been proud and honored to provide anesthesia care for our past and present military personnel and their families.  From the Civil War to the present day, nurse anesthetists have been the principal anesthesia providers in combat areas of every war in which the United States has been engaged.  In May 2003, at the beginning of “Operation Iraqi Freedom,” 364 CRNAs had been deployed to the Middle East to ensure military medical readiness capabilities.  For decades CRNAs have staffed ships, remote US military bases, and forward surgical teams, often without physician anesthesiologist support.  The US Army Joint Special Operations Command Medical Team and Army Forward Surgical Teams are staffed by CRNAs. 

As our military personnel advance from active service to retired and Veteran status, their anesthesia care in VA facilities is provided predominantly by nurse anesthetists.  In 12% of VA healthcare facilities, the necessary anesthesia services are provided solely by CRNAs, ensuring our Veterans the safe anesthesia care that they deserve and have earned.

Our tradition of service to the military and our Veterans is buttressed by our personal, professional commitment to patient safety, made evident through research into our practice.  In our professional associations, we state emphatically “our members’ only business is patient safety.”  Safety is assured through education, high standards of professional practice, and commitment to continuing education.  Having first practiced as registered nurses (RNs), CRNAs are educated to the master’s degree level, and some to the doctoral level, and meet the most stringent continuing education and recertification standards in the field.  Thanks to this tradition of advanced education and clinical practice excellence, we are humbled and honored to note that anesthesia is 50 times safer now than in the early 1980s (National Academy of Sciences, 2000).  Research further demonstrates that the care delivered by CRNAs, physician anesthesiologists, or by both working together yields similar patient safety outcomes.  In addition to studies performed by the National Academy of Sciences in 1977, Forrest in 1980, Bechtoldt in 1981, the Minnesota Department of Health in 1994, and others, Dr. Michael Pine, MD, MBA, recently concluded once again that among CRNAs and physician anesthesiologists, “the type of anesthesia provider does not affect inpatient surgical mortality ” (Pine, 2003).  Thus, the practice of anesthesia is a recognized specialty in nursing and medicine.  Most recently, a study published in Nursing Research confirmed obstetrical anesthesia services are extremely safe, and that there is no difference in safety between hospitals that use only CRNAs compared with those that use only anesthesiologists (Simonson et al, 2007).  Both CRNAs and anesthesiologists administer anesthesia for all types of surgical procedures from the simplest to the most complex, either as single providers or together.

NURSE ANESTHESIA PROVIDER SUPPLY AND DEMAND:
SOLUTIONS FOR RECRUITMENT AND RETENTION IN THE DVA

While both types of health professionals can provide the same high quality anesthesia care, CRNAs provide the DVA an additional advantage of cost-effectiveness.   Consequently, both our Veterans and our VA health system are best served by policies and initiatives that secure adequate numbers of CRNA employees in the DVA.  We believe that this Committee can help accomplish this objective by supporting nurse anesthesia education programs, both within the VA itself and in partnership with military and civilian schools of nurse anesthesia.

It is essential to understand that while there is strong demand for CRNA services in the public and private healthcare sectors, the profession of nurse anesthesia is working effectively to meet this workforce challenge.  The AANA anticipates growing demand for CRNAs.  Our evidence suggests that while vacancies exist, the demand for anesthesia professionals can be met if appropriate actions are taken.  As of January 2008, there are 108 accredited CRNA schools to support the profession of nurse anesthesia.  The number of qualified registered nurses applying to CRNA schools continues to climb.  The growth in the number of schools, the number of applicants, and in production capacity, has yielded significant growth in the number of nurse anesthetists graduating and being certified into the profession.  The Council on Certification of Nurse Anesthetists reports that in 2007, our schools produced 2,021 graduates, an 88% increase since 2002, and 1,869 nurse anesthetists were certified.  The growth is expected to continue.  The Council on Accreditation of Nurse Anesthesia Educational Programs (COA) projects the 108 CRNA schools to produce over 2,300 nurse anesthetists in 2008.

The number of VA anesthesia vacancies is causing us concern.   We believe that they can be filled through creative partnership between the VA system and the profession of nurse anesthesia, and commitment by the DVA to effectively recruit and retain CRNAs.  More than half of the VA nurse anesthesia workforce is over the age of 53, an age some years above the mean for all CRNAs nationally.    The annual turnover and retirement rate among CRNAs within the VA has risen to about 19% over the past few years and continues to rise as the workforce ages, more lucrative employment is offered in the private sector, and new graduates from CRNA educational programs find the VA employment and practice package comparatively uncompetitive.   Currently, 24 stations show vacancies on public Federal job posting sites.  However, we have reason to believe that the numbers of stations with actual vacancies is closer to 40, with staff vacancies either being left vacant for extended periods of time, or filled by contract personnel.  Approximately 150 CRNA slots in the DVA are being filled by contract personnel. 

As the nurse anesthesia profession is working to meet the demand for CRNAs generally, we believe that the DVA specifically can meet its CRNA recruitment needs by pursuing three strategies.  First, DVA should expand its relationships with existing CRNA schools.  Second, the DVA should expand its joint CRNA educational program together with the Department of Defense (DOD) health system.  Third, the DVA should upgrade its recruitment, retention, and practice environment factors to make VA service more competitive with the private market for anesthesia services, within the context of the DVA’s mission. 

To a degree, some of these strategies are already under way and achieving results for the VA health system.  A recent AANA survey shows our nurse education programs use some 70 VA hospitals and healthcare facilities as clinical practice education sites, helping to educate CRNAs, provide superior patient care, and aid the VA in recruiting nurse anesthetists.  In addition, we recommend that the DVA pursue nurse anesthesia resource sharing programs with civilian CRNA schools through faculty exchange initiatives.  

Because nurse anesthesia is a safe and highly cost-effective means to secure anesthesia services for our Veterans, we have expressed concern that the DVA has introduced “anesthesiologist assistants” (AAs) to the VA health system, through new qualifications standards that do not require them to be licensed in any state, or subject to any state’s oversight or discipline, or to have graduated from an accredited educational program, or to have secured certification, or to be appropriately supervised by anesthesiologists in a manner consistent with AAs’ training as assistants.  Though the DVA handbook VHA-1123 updated March 2007 authorizes anesthesiologists to delegate anesthesia care to unqualified, uncredentialed individuals, the VHA has not yet hired such individuals.   There are other substantive concerns with the handbook.  Our Veterans deserve better.  We have requested the  policy be withdrawn, and have met with the agency to promote our shared interest in ensuring our Veterans access to safe, high quality anesthesia care.

US ARMY – VA  JOINT PROGRAM IN NURSE ANESTHESIA
FT. SAM HOUSTON, SAN ANTONIO, TX

The establishment of the joint US Army-VA program in nurse anesthesia education at the U.S. Army Graduate Program in Anesthesia Nursing, Ft. Sam Houston, in San Antonio, TX holds the promise of making significant improvements in the VA CRNA workforce, as well as improving retention of VA registered nurses in a cost effective manner. The current program utilizes existing resources from both the Department of Veterans Affairs Employee Incentive Scholarship Program (EISP) and VA hospitals to fund tuition, books, and salary reimbursement for student registered nurse anesthetists (SRNAs).

This VA nurse anesthesia program started in June 2004 with three openings for VA registered nurses to apply to and earn a Master of Science in Nursing (MSN) in anesthesia granted through the University of Texas Houston Health Science Center.  In the future, the program is granting degrees through the Northeastern University Bouve College of Health Sciences nurse anesthesia educational program in Boston, Mass.  Due to continued success and interest by VA registered nurses for the school, the program increased to five openings for the June 2005 and 2006 classes.  This program continues to attract registered nurses into VA service, by sending RNs the strong message that the VA is committed to their professional and educational advancement.  In order to achieve the goal of expanding the program further,, it is necessary for full funding of the current and future EISP to cover tuition, books, and salary reimbursement. 

The 30-month program is broken down into two phases.  Phase I, 12 months, is the didactic portion of the anesthesia training at the U.S. AMEDD Center and School (U.S. Army Graduate Program in Anesthesia Nursing).  Phase II, 18 months, is clinical practice education, in which VA facilities and their affiliates would serve as clinical practice sites.  In addition to the education taking place in Texas, the agency will use VA hospitals in Augusta, Georgia, increasing Phase II sites as necessary.  Similar to military CRNAs who repay their educational investment through a service obligation to the U.S. Armed Forces, graduating VA CRNAs would serve a three-year obligation to the VA health system.  Through this kind of Department of Defense – DVA resource sharing, the VA will have an additional source of qualified CRNAs to meet anesthesia care staffing requirements. 

At a time of increased deployments in medical military personnel, VA-DOD partnerships are a cost-effective model to fill these gaps in the military healthcare system. At Ft. Sam Houston nurse anesthesia school, the VA faculty director has covered her Army colleagues’ didactic classes when they are deployed at a moments notice.  This benefits both the VA and the DOD to ensure the nurse anesthesia students are trained and certified in a timely manner to meet their workforce obligation to the Federal government as anesthesia providers.  

We are pleased to note that the Department of Veterans’ Affairs Acting Deputy Under Secretary for Health and the U.S. Army Surgeon General approved funding to start this VA nurse anesthesia school in 2004. In addition, the VA director has been pleased to work under the direction of the Army program director LTC Thomas Ceremuga, CRNA, PhD to further the continued success of this US Army-VA partnership.  With modest levels of additional funding in the EISP, this joint US Army-VA nurse anesthesia education initiative can grow and thrive, and serve as a model for meeting other VA workforce needs, particularly in nursing.

We recently recommended that $400,000 be included in the FY 2009 appropriations to expand this joint educational program.

LOCALITY PAY

In order to meet demand for nurse anesthetists, each VA facility’s administrator may make use of existing locality pay structures as authorized and funded by Congress.  Competitive salaries assist the DVA with retention of CRNAs to provide anesthesia services for our nation’s veterans.  Though providing competitive salaries for excellent employees is an ongoing challenge, using locality pay to keep personnel is most cost-effective.  This is where Congress can help, by providing adequate funding for personnel through locality pay adjustments where base salaries are not sufficiently competitive with the local private market.  Further, this Subcommittee should examine whether the 2004 authorization to expand incentive professional pays for physicians and nurse executives should also be applied to the recruitment and retention of nurse anesthetists, or, alternatively, whether other means should be pursued to lift the statutory cap that keeps VA nurse anesthetist compensation below local market levels.

For several reasons, ensuring sufficient locality pay flexibility is in the interest of both our VA and our Veterans.  The DVA faced a severe shortage of CRNAs in the early 1990s, which was moderately corrected with the implementation of a locality pay system in 1991.  In 1992, Congress expanded the authority to the local medical directors and allowed them to survey an expanded area to determine more competitive average salaries for CRNAs, which boosted pay and morale.  Implementation of this expanded authority helped assist the DVA in making great leaps in retention and recruitment of CRNAs at that time.  However, times and the local labor markets for healthcare professionals have continued to change.  In the past few years CRNAs’ salaries have increased in the private sector, while the VA has not adjusted to these new salary rates.  This means that in some markets the DVA locality pay system is no longer competitive with the private sector, and new nurse anesthetist graduates are choosing not to work in the VA health system.  We believe that the VA would benefit by providing CRNAs competitive salaries in VA facilities and making use of effective locality pay adjustments, which reduces VA hospital administrators’ requirements for contracted-out services at higher rates.

Though nurse anesthetists provide the lion’s share of anesthesia services to U.S. Department of Veterans Affairs (VA) healthcare facilities, the agency is facing a wave of retirements and having challenges recruiting CRNAs because the compensation it offers is below local market levels, a Government Accountability Office (GAO) report highlighted (“Many Medical Facilities Have Challenges in Recruiting and Retaining Nurse Anesthetists,” GAO-08-56, 12/13/2007)  The GAO recommended that the VA apply its locality pay system more vigorously to recruit and retain nurse anesthetists.

At the time the report was issued, the AANA issued a statement, saying, “The profession of nurse anesthesia is committed to caring for our nation’s Veterans.  Nurse Anesthesia continues to be a safe, flexible and highly cost-effective means for the VA to ensure our Veterans the healthcare that they need and deserve.  We look forward to continuing work with the Department of Veterans Affairs, the Congress, and the members of the Association of Veterans Affairs Nurse Anesthetists (AVANA) to help carry out the recommendations of this report.”

The GAO found that VA medical facilities have had to temporarily close operating rooms or delay elective surgeries due to a shortage of CRNAs.  While demand for CRNA services is increasing, the report says 26 percent of the VA’s CRNAs are projected to retire or leave the department in the next five years.  The GAO said that the VA’s CRNA recruitment and retention challenges are caused primarily by the agency’s below-market compensation compared with local market conditions around the country.  The GAO made its findings based on surveys of VA CRNAs, VA managing personnel in local VA facilities and at VA headquarters, and through other data sources.  The report says the nurse anesthesia profession has been working effectively to meet high U.S. demand for anesthesia workforce by increasing the number of qualified practitioners graduating from accredited nurse anesthesia programs.

The report recommended that the agency deploy and carry out its existing locality pay system to adjust salaries so that they are more competitive.  Any locality pay system should be structured to set competitive salary levels for nurse anesthetists working in VA healthcare facilities. The DVA could implement a system that guarantees accurate surveys on pay are being conducted in a timely manner.  This salary data will be used to adjust Nurse 1 (Step 1) to be competitive within the local market to assist VA facilities in hiring new nurse anesthesia graduates.

Finally, with adjustments in the pay structure to include professional pays for recruitment and retention of CRNAs, VA facilities may well realize cost savings by contrast with other arrangements for securing anesthesia services.  

Recently, Senator Daniel Akaka (D-HI) introduced the Veterans’ Medical Personnel Recruitment and Retention Act of 2008 (S. 2969), and several of its provisions are intended to help the VA recruit and retain CRNAs to the VA healthcare system.  We applaud Senator Akaka’s efforts to bring VA healthcare professionals’ pay closer to the private sector.  Our first priority remains ensuring our Veterans’ access to a high quality of healthcare.   The quality of healthcare services, and the qualifications expected of healthcare professionals, and the numbers of healthcare professionals, all together have bearing on the quality of life of our Veterans, and should be kept in mind in equal measure.

CONCLUSION 

In conclusion, we recognize that the VA has nurse anesthesia staffing needs.  Through an effective partnership with the nurse anesthesia profession, the DVA can help meet its future CRNA workforce requirements through three cost-effective models, which exist today and can be expanded.  Our VA hospitals can serve as clinical practice sites for CRNA schools.  Going one step further, the VA health system can pursue resource sharing and faculty exchange agreements with nurse anesthesia schools.  Further still, the VA and DOD can share resources outright to educate nurse anesthetists for the Veterans and military settings alike, particularly with modest additional funding.  This VA commitment to CRNA education helps secure the nurse anesthesia workforce our Veterans need, and attracts registered nurses into VA service, by sending the strong message that the VA is committed to RNs’ professional and educational advancement.  Last, the VA should examine and improve the effectiveness of its recruitment, retention and practice environment for CRNAs.

Thank you.  If you have further questions, please contact the AANA Federal Government Affairs Office at 202-484-8400.