Independent CRNA Practice: Policy, Reality, and Risk
An opinion piece by NAVAPD Board Member Wayne Johnson, M.D.
The question of independent Certified Registered Nurse Anesthetist (CRNA) practice is often framed as a simple yes-or-no issue. In reality, the landscape is far more nuanced—shaped not only by state law, but by hospital policy, patient complexity, and institutional risk tolerance.
National Landscape: Mixed, With Limits
Nationally, the trend toward CRNA independence is uneven. Approximately 25 states have opted out of the federal requirement for physician anesthesiologist supervision. However, state law alone does not determine how anesthesia care is delivered.
Even in opt-out states, hospitals retain full authority to set their own credentialing and supervision requirements. As a result, many hospitals—by choice—continue to require anesthesiologist involvement despite permissive state statutes.
Hospital Reality: Where Policy Meets Practice
This is the critical point often missed in public debate: across the United States, a substantial number of hospitals do not allow fully independent CRNA practice, regardless of state opt-out status.
Physician-led anesthesia models remain the norm, particularly in:
Large health systems
Academic medical centers
Urban and tertiary referral hospitals
Common models include:
Medical Direction (one anesthesiologist overseeing up to four CRNAs)
Medical Supervision (a less restrictive but physician-involved model)
Care Team models, which dominate many integrated systems
By contrast, CRNA-only practice is most commonly found in:
Small rural hospitals
Critical access hospitals
Facilities facing significant anesthesia staffing shortages
Cost-constrained or resource-limited systems
Why Hospitals Restrict Independent CRNA Practice
Hospitals that require anesthesiologist involvement consistently cite system-level considerations rather than individual provider capability. These include:
Patient safety and enterprise risk management
High-acuity and complex case mixes (trauma, ICU, transplant services)
Malpractice coverage and liability structure
CMS and payer expectations
Institutional culture and credentialing standards
It is important to be clear: these policies are not judgments on the skill or professionalism of CRNAs. Rather, they reflect how institutions manage risk across complex systems of care.
The VA Perspective
Within the Veterans Health Administration, anesthesia practice authority is locally determined, but clear patterns exist:
Many VA facilities require anesthesiologist involvement or supervision
Larger VA medical centers are far less likely to permit independent CRNA practice
As a system, the VA is risk-averse and policy-driven, favoring physician-led care models—particularly in high-acuity environments
This approach aligns with the VA’s broader emphasis on standardized care, accountability, and patient safety.
Bottom Line
In plain terms:
It is entirely normal—and defensible—for hospitals to require MD anesthesiologist supervision
Hospitals do this every day, even in states that allow CRNA independence
In high-acuity hospitals, independent CRNA-only practice is the exception, not the rule
Understanding this distinction between state law and hospital policy is essential to having an honest, informed discussion about anesthesia care in the United States.
NAVAPD’s Stance
NAVAPD remains deeply concerned, as this precedent could be replicated at other VA facilities, potentially putting patients at risk for adverse outcomes, including death, at the hands of nurses whose training does not match that of physician anesthesiologists.
About the Author
Wayne Johnson, M.D. is a board-certified orthopaedic surgeon with more than 26 years of surgical experience and 34 years in medicine. He serves as Chief of Orthopaedic Surgery at the Oklahoma City VA Medical Center, where he leads a subspecialized practice in knee and shoulder arthroscopy.
Dr. Johnson is an Assistant Clinical Professor at both the University of Oklahoma and Oklahoma State University, mentoring orthopaedic residents in urban and rural settings. He has held numerous leadership roles, including President of the Oklahoma State Orthopaedic Society and Chair of the American Academy of Orthopaedic Surgeons (AAOS) Board of Councilors. Nationally, he currently serves as Chair of the AAOS Orthopaedic Political Action Committee (OrthoPAC) and Vice President of the J. Robert Gladden Orthopaedic Society.
Throughout his career, Dr. Johnson has remained deeply committed to advancing orthopaedic care, promoting diversity and inclusion, and mentoring the next generation of physician leaders. His work reflects a sustained dedication to service, education, and advocacy at both the local and national levels.