There is currently a federal requirement that Certified Registered Nurse Anesthetists (CRNAs) must be supervised by a physician when providing anesthesia services. However, in 2001, the Centers for Medicare and Medicaid ruled that states may independently opt-out (become exempt) from the federal rule of supervision.

There are multiple reasons why opt-out is important. First, it eliminates confusion that the term “supervision” entails. CRNAs provide the majority of anesthesia within the rural communities in the United States, often without an Anesthesiologist within hours of the facility. Therefore, the supervision tends to fall onto the surgeon/dentist/podiatrist etc. For these providers, the idea of “supervising” can create fear of liability that is unnecessary. Next, physician supervision has not proven to increase the safety of care. Multiple studies have proven that anesthesia care is equally safe regardless of being administered by a CRNA or Anesthesiologist. Ultimately, opt-out allows local control for facilities to decide on how they can best approach quality care for their patients. Overall, there are currently 17 states that have implemented opt-out (see image below1). Hopefully Arizona will join the other 17 states and opt-out sometime in the future.

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1. Simpson, C. (2012). State beat: 2012 summary of state activities. Retrieved from


6 thoughts on “Introduction

    1. Hey Dr. Ross,

      In March 2015, I was elected to the Board of Directors for the Arizona Association of Nurse Anesthetists. As I have become more active politically, I have gained insight into the importance of opt-out in our profession. Specifically, this was most evident after speaking with CRNAs who practice in rural areas of states that have already opted-out and how it has benefited them. It will be intriguing to see our future approach in Arizona towards opt-out and if we can ultimately be successful at achieving it.



    2. I was not familiar with CRNA’s scope of practice until last semester when I had to do an assignment on the regulatory oversight of CRNA’s in Arizona. I think its awesome that the Centers for Medicare and Medicaid created the opt-out options for states. I know that in Arizona CRNA’s do not have independent practice privileges or independent prescriptive authority. CRNA’s often practice in rural areas and are the sole provider of anesthesia. As you mentioned this becomes problematic when CRNA’s have a surgeon or a dentist as their “supervising” physician. It would be great for CRNA’s to practice to their full extent if Arizona opts out. Do you know if Arizona has expressed any interest in opting out?



      1. Hey Ramona,

        Thank you for your post. You are correct, it is very strange that we have CRNAs practicing “independently” but with the clause of “physician supervision”. In most circumstances, in these facilities the supervising physician has minimal knowledge of anesthesia. It unfortunately muddies the water when it comes to independent practice. In regards to AZ specifically, I’m anxious to see the outcome of the Sunrise Application. The physician supervision language is a major aspect of what the CRNAs are attempting to get changed. When this restrictive language is removed from statute, then AZ will be on the right track for opting-out.



  1. Hi Lee. Thanks so much for bringing up this topic. I have to admit that I was somewhat unsure of the stipulations/regulations of a CRNA. I appreciate getting to learn about this topic going forward. In reading more about this topic, I learned about the “select, order, and administer” rule that most CRNAs are bound to without prescriptive authority. I think with the upcoming Sunrise Report Legislation will be critical towards Arizona giving CRNAs the opt-out opportunity and full prescriptive authority. I look forward to reading more about this topic especially with today’s political climate!
    Barbara Schulte, RN


    1. Thanks Barbara,

      As you are well aware, the Sunrise Application has major implications for all APRNs in AZ. I have obviously focused on the CRNA side of things, but have tried to increase my knowledge for what the other APRNs are looking for as well. Statute language and its interpretation tends to be a common issue for all specialties. Due to the volatile environment surrounding narcotic prescription issues, that aspect of prescribing has been taken off the table. This ability would have mainly assisted those CRNAs who are working in pain management. However, with the current narcotic crisis, it is just not the right time. It will be very interesting to follow this legislation during this semester, what great timing for a health policy class.



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