Attachment 1 - AANA comment

February 19, 2010

Department of Health & Human Services
Health Resources and Services Administration (HRSA)
Attn: Desk Officer for HRSA
Parklawn Building
5600 Fishers Lane
Rockville, MD 20857

RE: HRSA Proposed Project: Advanced Education Nursing Traineeship (AENT) and
Nurse Anesthetist Traineeship (NAT) (OMB No. 0915-0305) [Extension], (74 Fed.Reg.
3739, January 22, 2010)
Dear HRSA Desk Officer:
The American Association of Nurse Anesthetists (AANA) would like to take this opportunity to
share with you some of our thoughts and suggestions regarding the HRSA Proposed Project:
Advanced Education Nursing Traineeship (AENT) and Nurse Anesthetist Traineeship (NAT)
(OMB No. 0915-0305) [Extension], (74 Fed.Reg. 3739, 01/22/10). We applaud HRSA for
making funding through these programs possible and available to nurse anesthesia education
programs throughout the country.

Background of the AANA and CRNAs
The AANA is the professional association for more than 40,000 Certified Registered Nurse
Anesthetists (CRNAs) and student nurse anesthetists, and through their membership represents
over 90 percent of the nurse anesthetists in the United States. CRNAs are advanced practice
registered nurses who personally administer about 32 million anesthetics to patients each year in
the United States, according to the 2008 AANA Member Survey. Nurse anesthetists have
provided anesthesia in the U.S. for nearly 150 years, and their high quality cost effective
anesthesia services continue to be in high demand today. CRNAs are Medicare Part B providers
who have been authorized to bill Medicare directly for 100 percent of the physician fee schedule
amount for their services since 1989,

American Association of Nurse Anesthetists Office of Federal Government Affairs
25 Massachusetts Ave. NW, Suite 550, Washington, DC 20001 / ph 202-484-8400 / fx 202-484-8408 / www.aana.com

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CRNA services include the perioperative preparation and management of patients, administering
the anesthetic, monitoring and interpreting the patient's vital signs, and managing the patient
throughout surgery. CRNAs also provide acute and chronic pain management services. CRNAs
provide anesthesia for a wide variety of surgical cases and in some states are the sole anesthesia
providers in nearly 100 percent of rural hospitals, affording these medical facilities obstetrical,
surgical, and trauma stabilization, and pain management capabilities.

According to a 2007 Government Accountability Office (GAO) study, CRNAs are the
predominant anesthesia provider where there are higher densities of Medicare beneficiaries and
where the gap in reimbursement between Medicare and private pay is less.1 Nurse anesthesia
predominates in Veterans Hospitals and in the U.S. Armed Forces. CRNAs work in every
setting in which anesthesia is delivered including hospital surgical suites and obstetrical delivery
rooms, ambulatory surgical centers (ASCs), pain management facilities and the offices of
dentists, podiatrists, and all varieties of specialty surgeons.

HRSA Advanced Education Nursing Traineeship grants remain crucial for nurse
anesthesia education programs.
The Title 8 Advanced Education Nursing program, which includes grants through the Nurse
Anesthesia Traineeship (NAT) and the Advanced Nursing Education Traineeship (AENT)
programs, is extremely valuable in helping meet demand for nursing faculty and other advanced
education nursing services throughout the U.S. The program provides competitive grants that
help enhance advanced nursing education and practice, as well as traineeships for individuals in
advanced nursing education programs. This funding is critical to meet the nursing workforce
needs of Americans who require healthcare. Based on a 2009 Annual Report survey conducted
by the Council on Accreditation of Nurse Anesthesia Educational Programs (COA),

1

U.S. Government Accountability Office (GAO). Medicare Physician Payments: Medicare and Private
Payment Differences for Anesthesia Services. Report to Subcommittee on Health, Committee on Ways and Means,
U.S. House of Representatives. GAO-07-463. July 2007;15. http://www.gao.gov/new.items/d07463.pdf

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approximately 80% of all nurse anesthesia programs have students that rely on nurse anesthesia
traineeships funding to help support their education. The purposes of this funding are to increase
the number of providers in rural and underserved America and to prepare providers at the
master’s and doctoral levels, thereby increasing the potential number of clinicians who are
eligible to serve as faculty. We are grateful for your continued efforts to manage and provide
funding for all advanced practice nursing programs and in particular grants for nurse anesthesia
education programs.

The need for this program is justified by continued high demand for CRNA clinical and faculty
workforce. In 2007, an AANA nurse anesthesia workforce study found a 12.6% vacancy rate in
hospitals for CRNAs, and a 12.5% faculty vacancy rate. The supply of clinical providers has
increased in recent years, stimulated by increases in the number of CRNAs trained. From 2000
through 2008, the number of graduates of nurse anesthesia educational programs doubled, with
the Council on Certification of Nurse Anesthetists (CCNA) reporting 1,075 graduates in 2000
and 2,158 graduates in 2008. Because high demand for CRNA services are expected to drive this
growth continue, it is even more critical that funding for AENT and NAT grants remains
available. In addition, it is important to note that even though the number of graduates has
doubled in eight years, the nurse anesthetist vacancy rate remained steady at around 12%, which
is likely attributable to increased demand for anesthesia services as the population ages, growth
in the number of clinical sites requiring anesthesia services, and CRNA retirements.

The great challenge to meet continued high demand for CRNA workforce is not for a lack of
qualified applicants to our 109 accredited programs of nurse anesthesia; our educational
programs continue to turn away qualified applicants by the hundreds each year. Rather, the
capacity of nurse anesthesia educational programs to educate qualified applicants is limited by
the number of faculty, the number and characteristics of clinical practice educational sites, and
other factors. (A qualified applicant to a CRNA program is a bachelor’s educated registered
nurse holding a valid RN license in a state, who has spent at least one year practicing in an acute
care healthcare environment.)

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With the help of HRSA Advanced Education Nursing expansion grants as well as funding for
AENT and NAT, the nurse anesthesia profession is making significant progress, expanding both
the number of clinical practice sites and the number of graduates. Furthermore, AENT and NAT
grants help nurses (RNs) to become advanced practice nurses and pursue a career in nurse
anesthesia. The traineeship funding helps offset tuition, textbook expenses, fees and other costly
ancillary expenses associated with education. Our nurse anesthesia students report that this
funding is especially helpful in successfully pursuing their professional education.

AANA Request for AENT & NAT application process.
It is our understanding that advance practice nursing education programs can garner more grant
funding through AENT and NAT if the education programs can demonstrate that their programs
include students who are ethnic or racial minorities, and if the programs can demonstrate that
their graduates go on to provide healthcare services in designated Health Professional Shortage
Areas (HPSAs) or other medically underserved areas. We support HRSAs policies, which
promote diversity in the advance practice nursing workforce and access to advance practice
nursing services. We are especially proud of nurse anesthesia’s long record of providing access
to anesthesia services to patients living in rural and medically underserved areas of the country.

Our specific comments for HRSA’s AENT and NAT programs relate to the application process.
We thank you for the data base that HRSA has created which allows nurse anesthesia program
directors who are applying for grant funding to determine more precisely whether their graduates
are practicing in underserved areas. This is a very helpful resource for our program directors.
We appreciate the HRSA staff’s continued responsiveness to our nurse anesthesia program
directors’ questions, and welcome efforts by HRSA to make the AENT and NAT application
instructions clearer and crisper -- especially in correctly completing the table formulas that are
required for each grant application.

We thank you for the opportunity to comment on the AENT and NAT programs and we look
forward to continuing to work with you regarding nurse anesthesia and advanced practice

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nursing issues. Should you have any questions regarding these matters, please feel free to
contact the AANA Senior Director of Federal Government Affairs, Frank Purcell, at 202-4848400.

Sincerely,

James Walker, CRNA, DNP
AANA President
cc:

Wanda O. Wilson, CRNA, Ph.D. AANA Executive Director
Frank J. Purcell, AANA Senior Director of Federal Government Affairs
Pamela K. Blackwell, JD, AANA Associate Director, Federal Regulatory Policy
Ann Walker-Jenkins, AANA Associate Director, Federal Government Affairs