Opt-Outs

ASA Policy

In 2001, a final rule was adopted which amended the Medicare and Medicaid anesthesia Conditions of Participation (COPs) for hospitals, critical access hospitals (CAHs) and ambulatory surgical centers (ASCs). The final rule continued the requirement for physician supervision of nurse anesthetists but allowed state governors to “opt-out” of this requirement under certain circumstances. Since amending the Medicare safety rule, governors in 25 states have opted-out.

Since becoming law in 1966, Medicare has supported a team approach to anesthesia care, requiring that it be performed by a physician or a physician-supervised nurse anesthetist or physician anesthesiologist-supervised anesthesiologist assistant. The role of the physician anesthesiologist is to medically evaluate the patient’s fitness for surgery and anesthesia, determine potential risk, manage the patient’s medical condition during surgery, treat any medical complications and supervise post-operative care. In the absence of a physician anesthesiologist, there is only one other medical professional in the operating room with the education and training to perform these services: the surgeon.

ASA strongly opposes opt-out and believes it puts patients at risk. Opt-out decreases patient safety in operating rooms and hospitals, it does not improve access to care, it does not save the state or patients money, and it ignores the public’s preference for physician-led care. Opt-out is a failed policy experiment.

Nurse anesthetists are valued members of the anesthesia team, but their nurse education and limited clinical training does not equal the medical education and training of a physician. Nurse anesthetists are not trained in medical decision making, differential diagnoses, medical diagnostic interpretations or medical interventions. Removing physician supervision of anesthesia care makes no more sense than removing it from any other critical care location.

The 25 states that have opted-out are:

Iowa (December 2001)
Nebraska (February 2002)
Idaho (March 2002)
Minnesota (April 2002)
New Hampshire (June 2002)
New Mexico (November 2002)
Kansas (March 2003)
North Dakota (October 2003)
Washington (October 2003)
Alaska (October 2003)
Oregon (December 2003)
Montana (January 2004)
South Dakota (March 2005)
Wisconsin (June 2005)
California (July 2009)
Kentucky (April 2012)
Arizona (March 2020)
Oklahoma (November 2020)
Utah (February 2022: partial opt-out limited to Critical Access Hospitals and specified rural hospitals)
Michigan (May 2022)
Arkansas (May 2022)
Wyoming (May 2023: partial opt-out limited to Critical Access Hospitals and hospitals with 25 licensed beds or less)
Delaware (June 2023)
Colorado (2010 partial opt-out / 2023 full opt-out)
Massachusetts (May 2024)

To learn more about the importance of the patient centered, physician-led anesthesia care team, visit Made for This Moment or email [email protected].

Additional Resources