Assessing the impact of state “opt-out” policy on access to and costs of surgeries and other procedures requiring anesthesia services

Abstract

In 2001, the U.S. government released a rule that allowed states to “opt-out” of the federal requirement that a physician supervise the administration of anesthesia by a nurse anesthetist. To date, 17 states have opted out. The majority of the opt-out states cited increased access to anesthesia care as the primary rationale for their decision. In this study, we assess the impact of state opt-out policy on access to and costs of surgeries and other procedures requiring anesthesia services. Our null hypothesis is that opt-out rule adoption had little or no effect on surgery access or costs. We estimate an inpatient model of surgeries and costs and an outpatient model of surgeries. Each model uses data from multiple years of U.S. inpatient hospital discharges and outpatient surgeries. For inpatient cost models, the coefficient of the opt-out variable was consistently positive and also statistically significant in most model specifications. In terms of access to inpatient surgical care, the opt-out rules did not increase or decrease access in opt-out states. The results for the outpatient access models are less consistent, with some model specifications indicating a reduction in access associated with opt-out status, while other model specifications suggesting no discernable change in access. Given the sensitivity of model findings to changes in model specification, the results do not provide support for the belief that opt-out policy improves access to outpatient surgical care, and may even reduce access to outpatient surgical care (among freestanding facilities).

Addressing Provider Shortages in Rural America: The Role of State Opt‐Out Policy Adoptions in Promoting Hospital Anesthesia Provision

“…8 Costs in opt-out states have also not decreased relative to nonopt-out states. 9 Although scholars have made attempts to link the opt-out policy to such outcomes, the research could be viewed as incomplete due to the lack of examining organization-level outcomes; removing barriers to anesthesia service provision for hospital facilities in opt-out states is a major goal of the opt-out policy. 4 We aim to fill this gap by implementing multi-level generalized linear models to examine factors associated with CRNA utilization in US hospitals.…”

The Surgical and Anesthesia Workforce and Provision of Surgical Services in Rural Communities: A Mixed‐Methods Examination

“…29,30 In addition, our findings may also explain why previous studies did not observe that CRNA opt-out policies were associated with a difference in the use of elective anesthesia 15 or the proportion of patients having to leave their local ZIP Code for a surgery or access to inpatient surgical services. 15,16 If a majority of rural US counties completely lack various types of anesthesia providers needed to perform surgeries, with more than 80% having no anesthesiologist and 60% having no CRNA, we might not expect a difference in state policy to have any effect on surgical practice and payments of care providers if no providers are present in the county, let alone in the ZIP Code. At the same time, we found that CRNAs were often being used at the top of their license even in the presence of more restrictive state policies.…”

“…State governors have been allowed to “opt‐out” of Medicare's conditions of participation requirements since 2001; 17 states have done so as of 2018 15. The few previous efforts to discern the effects of these policies through quantitative data alone have not established a clear impact on access or utilization 15–18…”

“…15 The few previous efforts to discern the effects of these policies through quantitative data alone have not established a clear impact on access or utilization. [15][16][17][18]…”

Effects of opting‐out from federal nurse anesthetists' supervision requirements on anesthesiologist work patterns

“…Another study determined that CRNAs are a cost‐effective solution as they can provide care at a lower cost . Three other studies have indicated that state opt‐out have failed to yield significant improvements in patient access to anesthesia services . There is some evidence that opting‐out is related to higher CRNA supply in rural communities .…”