Clear, factual information regarding the roles and responsibilities of anesthesia care team members is increasingly difficult to find. In health care, “scope of practice” defines the range of responsibilities professionals may perform based on their license. As many state legislatures and Washington, D.C. are currently in session, anesthesiologists across the country are advocating for patient safety by promoting anesthesiologist-led care, not as part of a “scope” agenda, but as a matter of ensuring optimal care.
The myth of the opt-out state
For decades, nurse anesthetists have sought to expand their scope through legislation that would eliminate requirements for physician supervision or oversight. In doing so, they often point to “opt-out states” as evidence that a nurse-only model of anesthesia care is common and permissible. Their mantra is: “Our state is an opt-out state, so nurse anesthetists can practice independently.” This is simply not true. In 2001, the Centers for Medicare and Medicaid Services (CMS) modified its rules to allow state governors to “opt out” of the federal requirement that physicians supervise nurse anesthetists. To date, governors in 25 states have opted out. However, CMS fully recognizes the authority of state laws and regulations, nearly all of which require supervision or other oversight of nurse anesthetists administering anesthesia. These state laws and regulations exist regardless of federal opt-out.
An opt-out does not change nurse anesthetists’ practice unless state law is also amended to remove oversight requirements. Some states mirror federal supervision standards, while others use different terminology (collaboration, coordination, delegation, direction), but the underlying expectation of physician involvement remains. As a result, very few states permit a nurse-only model of anesthesia care.
A real-world warning from California
A real-world example of the importance of physician-led care became clear in 2024, in the findings of California Department of Public Health (CDPH) federal complaint validation survey reports regarding two hospitals in Modesto, California. In the CDPH survey, Doctors Medical Center was found “to be in substantial noncompliance with the following conditions,” including the Code of Federal Regulation 42 482.52 Condition of Participation: anesthesia services.
At Doctors Medical Center, according to the report, surveyors determined there was “serious actual harm” to one patient and “serious potential harm to three other patients related to the unsafe practice of certified registered nurse anesthetists (CRNAs) providing anesthesia services outside of the scope of practice for CRNAs.” The hospital had granted nurse anesthetists full prescriptive authority without having the authority to do so, permitted CRNAs to diagnose and treat patients without a physician order establishing treatment regimens, which is outside their scope of practice, and had not followed governing body and medical staff bylaws in the credentialing and privileging process of CRNAs, according to the report. Regulators called an “immediate jeopardy situation” on May 23, 2024, a severe sanction, that in the report concluded that the hospital’s noncompliance “has caused or is likely to cause serious injury, harm, impairment or death to a patient.”
Opt-out does not protect hospitals
The Modesto case illustrates what can go wrong in opt-out states when state law, hospital bylaws, and rules requiring physician orders are not followed. Federal opt-out status does not shield facilities from state enforcement, nor did it insulate them from findings of immediate jeopardy. Hospital leaders should take note: “Opt-out” status does not eliminate regulatory obligations. As the Modesto cases demonstrate, when hospital policies drift from statutory requirements or fail to ensure appropriate physician oversight, regulators respond. Credentialing, privileging, supervision, and peer review processes are not administrative formalities; they are core patient safety mechanisms.
Patient safety, not slogans, should drive policy
Opt-out is a failed policy experiment and a dangerous workaround that undermines patient safety. Physician-led anesthesia care is important not because of professional preference, but because it aligns with evidence, governance responsibility, and patient expectations. As legislatures debate scope expansion, policymakers and hospital C-suite executives should ground their decisions in data, regulatory reality, and patient safety, not slogans. Physician-led anesthesia care is important because it is what patients want and expect, but anesthesiologists support it because it is what is best for patients.
Michael Beck is an anesthesiologist.
