Download this proposal as a PDF.

Commenting for this proposal will be open until the close of business on Monday, June 5.

Title of Proposal:

Licensure of Certified Anesthesiology Assistants

On behalf of:       

Virginia Society of Anesthesiologists

Describe the Idea or Issue:

The Virginia Society of Anesthesiologists (VSA) requests that the Medical

Society of Virginia advocate for a bill permitting the licensure of certified anesthesiologist assistants (CAAs) in the Commonwealth during the 2018 General Assembly Session.

Desired Outcome:

The VSA requests that the Medical Society of Virginia advocate for a bill permitting the licensure of CAAs in the Commonwealth during the 2018 General Assembly Session. This is an issue that should be important to the House of Medicine, not just to anesthesiologists, because it impacts:

  • Provider shortages
  • Access to care
  • Economic efficiencies and optimization
  • Selection of mid-level practitioner to best suit patient needs

Licensure of CAAs would help alleviate all of these issues, so we are seeking the support of the entire community of medicine in this endeavor.

Background/Supporting Information:

CAAs are highly skilled health professionals who work under the direction of licensed physician anesthesiologists to implement anesthesia care plans. All CAAs possess a premedical background, a baccalaureate degree and complete a comprehensive didactic and clinical program at the master’s level.

CAAs work exclusively within the anesthesia care team environment and, unlike nurse anesthetists; they must be supervised by a physician anesthesiologist.

Eighteen jurisdictions as well as the District of Columbia currently regulate CCAs. Virginia is surrounded by other states that have already adopted the CAA approach (North Carolina, Washington, D.C., Kentucky and Ohio).

There are 10 accredited CAA educational programs in the U.S. There are nearly 2,000 CAAs already practicing throughout the nation.

Eighteen jurisdictions as well as the District of Columbia currently regulate CCAs. Virginia is surrounded by other states that have already adopted the CAA approach (North Carolina, Washington, D.C., Kentucky and Ohio).

CAA students currently rotate through Virginia hospitals, but must go elsewhere to work when they finish training. There are currently about a dozen CAAs who reside in Virginia but travel to work elsewhere (including Arlington, Alexandria, Danville, Fort Royal and Williamsburg).

Anesthesiologists are the only physicians in the Commonwealth with only one physician-extender option (nurse anesthetists). CAAs would provide an additional choice of physician-extenders for anesthesiologists who adhere to the Anesthesia Care Team model of patient care.

CAAs are recognized by CMS, Tricare and all major commercial payers. Data from the Bureau of Labor and Statics shows that the cost of nurse anesthetists decreases in the states with the highest number of CAAs:

Mean Wage

Nationwide Rank in CAA Employment

  • Georgia - $137,940 - 1
  • Florida - $143,870 - 2
  • Ohio - $152,310 - 3
  • Texas - $161,740 - 4
  • Missouri - $151,330 - 5
  • Virginia - $171,160 - None

*Note – Texas is likely still above average because the 130 CAAs don’t compete significantly with the 32,000 nurse anesthetists statewide.

The VSA has been studying CAAs for several years, and has watched with interest as other states have adopted CAA licensure. The VSA surveyed its members in August of 2015, and found that:

  • 88% of its members thought that having CAAs as an available physician extender alternative to nurse anesthetists would be a good for anesthesiologists in Virginia.
  • 74% of members said that their current practice would use at least one CAA as an alternate physician extender.
  • 42% of members said that their current practice would use more than five CAAs as an alternate physician extender.

The Virginia Department of Health Professions is currently evaluating the feasibility of state licensure for CAAs. The Virginia Society of Anesthesiologists plans to pursue legislation licensing CAAs during the 2018 Genera Assembly Session.

Additional background materials in appendix.


As Past President t of the Virginia Society of Anesthesiologists, and a S a former member of the Board of Directors of the American Society of Anesthesiologists, I have studied this proposal in depth on the state and National levels and fully support the Proposal for Virginia . It will improve access and quality of care to patients. 

As a practicing anesthesiologist, I fully support anesthesia assistants in the state of Virginia.


I support this effort due to the markets need for providers in the care team model. CAA licensure would provide a more competitive environment & enhance access to care.

I have been a practicing Anesthesiologist in Virginia for 29+ years.  CAAs would allow another option when practicing in the care team model and would help to reduce the shortage of physician extenders in Anesthesia.  Thanks for your support.

I very much support this measure as I believe CAA's will improve patient safety and access to care. 

As a practicing anesthesiologist in Lynchburg VA I can attest to the significant need for additional anesthesia providers. In central VA we frequently experience difficulty recruiting providers, particularly nurse anesthetists (CRNAs). Because of the shortage of CRNAs their compensation level continues to escalate. This significantly impacts the cost of supplying anesthesia services at all hospitals in VA.

Please move forward with the proposal to bring these additional anesthesia providers to VA.  They have proven a proven record of safe and effective care working in conjunction with anesthesiologists. 

I have worked with CAAs as an anesthesiologist and they are great.  Much better care providers than CRNAs and Virginia should really make an effort to get this approved for our patients!  

I strongly support this reform/bill.  Keep up the good work and ty for your time and commitment to helping our patients.


Rick Lee MD


I support the licensure of CAA in Va as an alternative to CRNAs.  They will add competition and a different attitude to the Care Team Model.


I strongly support efforts to allow Anesthesia Assistants to practice in my state of Virginia.

Todd Lasher, MD

Department of Anesthesiology 

Carilion/Virginia Tech School of Medicine 


I am responding in favor of CAA licensure in Virginia.  CAAs are safe and effective members of the anesthesia care team, and practice in the District of Columbia and the neighboring state of North Carolina.  There is a significant shortage of anesthesia providers in Virginia -- my company alone has 30 open requisitions for CRNA positions that we cannot fill.  Numerous CAAs live in Virginia and pay taxes in Virginia, yet cannot work in the state.  Finally, anesthesiologists are the only physicians in the state with only one option of care extenders.  Once again, I am strongly in favor of this proposal.  Please don't hesitate to contact me with questions.

Virginia anesthesiologists should have a choice of physician extender who adheres to the anesthesia care team model. Patients benefit from having at least 2 anesthesia professionals involved in their surgical care. The extra set of eyes and extra set of hands can be really helpful, particularly in urgent or emergent scenarios. Virginia citizens who are CAAs deserve to have the opportunity to live and practice in their home state.


I support the exploration of using CAA in the OR setting. It is very strange that CAA's can train in Virginia but cannot practice here. I think they should be allowed to practice in Virginia and for hospitals and anesthesiologist to have the choice of using them. 

I am a practicing Anesthesiologist in Virginia and I am in full support of bringing CAAs into our care team model to further improve access to anesthesia care.

As an anesthesiologist in Virginia, I support bringing AA's to our state.


Greg Weiss MD

I am in full support of Anesthesiology Assistants in Virginia. They will be great assets in the Anesthesia Care Team Model headed by Anesthesiologists. This will prove to be the safest model for Virginia's patients undergoing surgery and Anesthesia.

I support AAs in Virginia. I have worked with them in GA and found them to be well educated members of the Anesthesiology Care team. 

i strongly support the licensure of AAs in the commonwealth of Virginia.

I am in full support of AA licensure in Virginia

i support CAAs in Virginia.

I'm in full support of the Anesthesia care team model 

Advanced practice nurses work side by side with physicians' assistants in all areas of the medical system, including in Virginia. The operating room should be no different. There are RNFAs and PAs that assist with cardiac surgery, why should AAs and CRNAs not be able to work side by side in the anesthesia care team model. It seems like an artificial exception. 

     I am writing in support of this proposal. As an anesthesiologist with 28 years of experience and 24 years practicing in Virginia, I have seen the massive increase in demand for anesthesia services for  traditional operating room procedures, as well as an ever-increasing demand for anesthesia outside the operating room in endoscopy suites, cardiac labs, and in radiology departments, where interventional radiologists are doing procedures on very ill patients requiring anesthesia support.

     Our practice has had much difficulty in finding enough Certified Nurse Anesthetists to work along side the physician anesthesiologists to provide this  care. Licensure of Certified Anesthesiology Assistants would provide another much need source of providers to help us meet the expanding need for anesthesia services in this state. Much as physician assistants in many other specialities work along with nurse practitioners and physicians to provide patient care, the addition of the physician assistants with special training in anesthesia would be very beneficial to our patients.

    Any argument against licensure should take into consideration the motives of those who would oppose it. CAAs have proven to be safe and effective in providing anesthesia care under the supervision of physician anesthesiologists. Arguments to the contray are just not true. While some CRNA organizations might look upon CAAs as competition, I maintain that there is plenty of work to go around in this state.

     In conclusion I offer my strong support in adoption of this proposal, so that we anesthesiologists can continue to provide the care that Virginians deserve.


William S. Brosche, MD

Fredericksburg, VA 

i support the licensure of CAAs in Virginia.

Having a CAA whose licensure requires them to work under the medical direction of a physician anesthesiologist is advocating for patient safety as some states allow nurse practitioners (CRNAs) to practice independently without a physician.  CAAs have a background in premedical sciences just like physican assistants and medical doctors. I believe this is the foundation needed to truly comprehend the sciences needed to deliver safe and quality patient care. 

I have worked with AA students in our practice for the past 3 years. AAs are actually superior in training to CRNAs and have been shown to actually hold down salaries of physician extenders in states where they currently practice. We need to have AAs in Virginia as a physician extender alternative to CRNAs

As an anesthesiologist, I support the licensure of CAAs, both to increase personnel available to provide services and to take back control of some aspects of the practice of anesthesia that have been essentially lost to CRNAs

 Please allow certified anesthesiology assistance in the state of Virginia. They would offer a great option and perhaps some cost savings in the delivery of anesthesia care.

As an anesthesiologist, I support licensing CAA's in Virginia. 

I have worked in Loudoun County for over 27 years as an anesthesiologist.  We have employed CRNAs successfully and have had a very stable group.  Recently, we have grown and need to increase the number of CRNAs working at our hjospital and surgery center.

We have been looking to hire multiple CRNAs for over a year, and have not been successful.  This has not been true in the past.

As an aside, I was trained by CAAs at Emory University over 30 years ago.  CAAs are equal in knowledge and skill set to any CRNA I have met.  We have CAAs that are trained, grew up in Loudoun County, want to work right now in Loudoun County, and cannot.  We need the manpower now.

Thank you,





I strongly endorse the proposal to begin Certification of Anesthesiologist Assistants (CAA) in Virginia as is the case in North Carolina and several surrounding states. The ACA and if repealed and replaced by Republican plans with extended Medicaid and pre-existing disease patients adding 20-30 million more people to our already struggling healthcare  pproviders, mandate increasing  involvement of physician extenders. Anesthesiologists in states where CAAs are in practice Over whelmingly positively support their CAA s and the resulting effective team care model.  Increasingly complex care for patients that must be turned over in Operating Rooms quickly due to follow on patient/institutional OR utilization pressure necessitate expanded use of well trained extenders and CAAs are trained for integration in that role.  They represent a specific subset of Physician Assistants (PA) but as yet  only programs training CAAs are ready and certifiable for this role. I have trained Anesthesiologists in 3  US medical schools and now a 4th as an Adjunct Professor and am convinced of the need for CAA s in Virginia and all states. Armed with the most meager knowledge and insight of the modern operating room working environment, the performance pressures, documentation and data reporting requirements, injury risks to both patients and care providers, malpractice risks and the time and interpersonal/ interaction pressures, all simultaneously impacting Anesthesiologists , strongly advocate for the addition of highly trained support staff specifically trained for that role. The Certified Anesthesiologist Assistant is trained for that role and should be a part of the operating room medical health care teams in the Commonwealth of Virginia and all of the United States.

Dennis W Coombs, MD

Richmond, VA 23220


i am fully in support of legislation to promote certification of CAAs in Virginia. I believe they will bring much needed support to anesthesiologists and improve medical care at all levels of care in Virginia.

 I Highly support the licensure of CAAs in VA !!!!

Anesthesiologist assistants are highly trained group of providers that will help aleviate many of the problems we are currently facing. They will improve access to care while not driving up costs. We should follow the lead of other state medical societies in allowing them to practice in Virginia.

A much needed proposal.

CAA is essentially a PA, which have been practising in Virginia essentially in every specialty under the supervision of a physician. If a physician assistant can be licensed to practise in surgery/emergency medicine/primary care and other specialties in Virginia, there is no reason to deny a CAA's practice under the supervision of anestheiologist .

I have the joy of working with some wonderful CRNAs and believe that adding the option of CAAs would be beneficial to the practice of anesthsia in VA. I understand that in VA, anesthesiologists only have one option as their physician extender - CRNAs while every other specialty physician has a choice of hiring a PA or a NP.   CAAs are well-trained masters level anesthetists who appreciate the care team model and fully support them.

An a practicing anesthesiologist in a community hospital, I support the licensing of CAAs in Virginia.  My group would use several CAAs, if these physician extenders were allowed to practice in Virginia.  Currently, we have two vacancies that we are having trouble filling with CRNAs, and this has created difficulties for us in covering all of the staffing requirements for our hospital.

I emphatically ask you to support the licensure of Certified Anesthesia Assistants (CAAs) in Virginia. I have worked with them in Ohio and consider them at least equal to CRNAs in quality of care. These CCAs are well trained and without a doubt safe. CCAs also allow for another choice of anesthesia providers in the state of Virginia during a time of a shortage of CRNAs. It also allows current residents of our state to practice where they live. We currently have a high interest in both training and hiring CCAs in Virginia and we look forward to the opportunity. Please contact me if you have any further questions or concerns.

I support licensing Anesthesia Assistants to work in Virginia. 

As medicine increasly utilizes mid-level providers to meet the needs of an aging population, staffing constraints are increasingly becoming an issues.  Our health system has been challenged increasingly to meet staffing needs.  The addition of CAAs, highly skilled and certified adjuncts to our anesthesia teams, can only serve to improve the quality of care for our patients.

As an anesthesiologist who trained alongside nurse anesthetists and has been in private practice in Virginia for over 25 years, I would love to see AAs licensed to practice in Virginia. We currently teach AAs in our practice , and the students have been uniformly excellent and an asset to our team. They are a much more attractive alternative to nurse anesthetists for us. Please help us by enabling AAs to practice in Virginia!

Having worked with Anesthesiologist Assistant students in our hospital in Virginia over the past 3 years, I can attest to the excellent quality of AA training. Though we are currently an all-physician anesthesiology group, in the event we were to alter our model to one which resulted in supervision of cases performed by anesthesiology non-physician extenders, I would, without hesitation look to hire Anesthesiologist Assistants instead of nurse anesthetists (CRNAs). AAs are better-trained in that they have a premedical background as opposed to a nursing background, so they tend to approach patient issues from a medical standpoint. The students we have hosted have been superb. Virginia definitely needs to have the opportunity for AAs to practice within the Commonwealth. As it is, we are training AAstudents, but having to export their talent to other states due to lack of licensing within Virginia.

As a physician anesthesiologist, I fully support the institution of Certified anesthesiology assistants in the state of VA. I think they would be a huge asset to our practice group, allow safe and cost-efficient anesthesia care while being under the direct supervision of a physician anesthesiologist.  I know of numerous individuals in VA who would attend CAA school if they knew they could practice in VA.  

I support the use of CAAs in Virginia.They could assist anesthesiologists in providing care in a cost effective manner and give anesthesiologists additional alternatives in how to deliver that care.  

Certified Anesthesia Assistants (CAAs) are not licensed to practice in VA, largely due to the efforts of AANA. CRNAs in this state promote CRNAs as substitutes for MD Anesthesiologists and have successfully blocked the licensure of CAAs through lobbying efforts. As a Board certified MD Anesthesiologist with expertise in Cardiothoracic Anesthesia who has prctice in VA for over thirty seven years, I strongly support the licensure of CAAs. We employ CRNAs and use them in a "care team"  model as we have one Anesthesiologist providing medical direction for three CRNAs. We also have MD Anesthesiolgists providing direct Anesthesia care to patients. National Companies, such as NAPA promote independant practice of anesthesia by CRNAs and promote this model to hospital administrations as a more cost efficient model than the MD/CRNA care team model. CAAs are well trained professionals who have the expectation to work in a care team model. MD Anesthesiologists have more years of training than CRNAs or CAAs and it is imperative that MD Anesthesiologists lead the care team. The selection process and training rigor becoming an MD Anesthesiologist is far more extensive than that for any CRNA or CAA. It seems the designation as "physician extender" is somehow considered demeaning by the AANA as they promote physician replacement through legistation rather than education. The AANA promotes their cause by pointing to a shortage of Anesthesia Providers, but their efforts to keep CAAs out of the state of VA seem counter to this argument. Please help us preserve superior anesthesia care in our commonwealth and provide competition to control costs by supporting the licensure of Certified Anesthesia Associates.

I support the licensure of Certified Anesthesiologist Assistants in the state of Virginia.  If passed, it would give me the opportunity to work within the Anesthesia Care Team to increase access to anesthesia services for patients across the state.  As an AA student, I did a clinical rotation in VA and gained invaluable experience working with and learning from the MD's there.

As a practicing anesthesiologist in the Commonwealth of Virginia, I would like to add my name and support for the passage of this bill.

Sincerely yours,

Roger Pede, M.D.

Lynchburg, VA

Allowing these individuals to practice in Virginia will help with shortages of anesthesia personnel without sacrificing safety of patients

i fully support AA licensure

I am in support of the VSA to support legislation to license CAA (certified anesthesiologist assistants) for the Commonwealth of Virginia. This will increase physician extenders to provide necessary anesthesia services in our state and will make our state more competitive to recruit these highly skilled healthcare providers that are already licensed in nearby bordering states. Please support this necessary and vital legislation.

A Certied Anesthesia Assistant is the equivalent of a Physician's Assistant but only performs anesthesia with appropriate oversight from a physician Anesthesiologist.  There are advanced Nurse Practitioners practicing in the same capacity as PA's in all other medical sub-specialties. CAA's should be allowed to perform anesthesia similarly as the advanced nurse practioner equivalent, CRNA's,  in the state of Virginia do.  In fact, because the advising Physician is always a MD anesthesiologist for CAA's and not a surgeon, as in some cases for CRNA's, anesthesia performed by CAA's is a safer alternative.  Sugeons were trained to do surgery, not anesthesia.  Please allow the specialty-trained Anesthesiologists manage both anesthesia physician assistants, i.e. CAA's and the  advanced anesthesia nurse practioners, i.e. CRNA's, in the practice of anesthesia.  Patients deserve the care and safety provided by MD anesthesiologists for their anesthesia.  Let the surgeons concentrate on their surgery.


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