with the civilian sector. Two, in addition, we believe that other nursing colleagues in other critical shortage areas of practice should receive special pay as a retention tool as well. PROMOTION Third, promotion. The slowness and limited potential for promotion is a major disincentive to remaining in the service. Promotion is not only a recognition of excellence, it is a pay issue as well. Consequently, we believe that an exemption from the Defense Officer Personnel Management Act, DOPMA, grade constraints for all corps within the military medical departments is the appropriate remedy to this problem. Mr. MURTHA. Let me stop you there, and we will take a close look at your statement. You have always made good recommendations. We know you have the best interests of the Services in mind, and also dependents, when you make these recommendations, so we will take a good look at them and work with you and see what we can do. Mr. RIVERA. Thank you, sir. [The statement of Mr. Rivera follows:] STATEMENT of the AMERICAN ASSOCIATION OF NURSE ANESTHETISTS before the AANA HOUSE COMMITTEE ON APPROPRIATIONS SUBCOMMITTEE ON DEPARTMENT OF DEFENSE APPROPRIATIONS on FISCAL YEAR 1993 APPROPRIATIONS by VICTOR RIVERA, BSN, CRNA MARYLAND ASSOCIATION OF NURSE ANESTHETISTS on APRIL 30, 1992 AMERICAN ASSOCIATION OF NURSE ANESTHETISTS - FEDERAL GOVERNMENT AFFAIRS OFFICE 777 North Capitol Street, N.E., Suite 803, Washington, D.C. 20002 Phone: (202) 682-1267 Fax: (202) 682-1269 My name is Victor Rivera. I am a certified registered nurse anesthetist (CRNA) and the PastPresident of the Maryland Association of Nurse Anesthetists. Currently, I am a staff CRNA with the Anesthesia Care Team, P.C., at Providence Hospital in Washington, D.C. I am also a retired Army nurse anesthetist, having held the rank of Lieutenant Colonel. As the professional association that represents over 24,000 CRNAs, the American Association of Nurse Anesthetists (AANA) appreciates the opportunity to provide testimony regarding the shortage of CRNAs in the military and civilian communities, and make recommendations that we believe will help recruit and retain CRNAs within the military services. We are also very appreciative to this committee for the help that you have given us in trying to assist the Department of Defense (DOD) and each of the military services to recruit and retain CRNAs. Our testimony will address the following issues: Operation Desert Shield/Storm, manpower, pay, promotions, practice, and education. Operation Desert Shield/Storm Special Pay The AANA appreciates the committee's help in remedying the inequity regarding special pay for reserve, recalled, and retained CRNAs and other health care providers involved in Operation Desert Shield/Storm. Due to the committee's direct intervention, the special pay for all health care providers involved in Operation Desert Shield/Storm, not just that of physicians and dentists, is now retroactive to August 1, 1990. Manpower A February, 1990 Health Economics Research study, mandated by the congressional appropriations committees, reported a total shortage of 6,000 CRNAs for 1990, or a 13.6 percent shortfall. It further reported the need for 30,000 CRNAs by the year 2000, and over 35,000 CRNAs by the year 2010. There is also a CRNA shortage in the military. The authorized levels in the three services for both active duty and reserve CRNA forces total about 1,600; the current actual levels for active duty and reserve CRNAs total about 1,000. Although there is a clear intent to downsize the number of military personnel generally, this does not create a concomitant need to decrease the number of anesthesia providers. The military health care mission has not been downsized in any way; the health care needs of military personnel and their families must still be met. Pay Approximately eight years ago, once military CRNAs reached the grade of major with 12-14 years service, they could expect their salary and fringe benefits to match that of the average employed CRNA in the civilian workforce, who often had attained that level in 2-4 years. Due to significant increases in civilian CRNA income in the past few years, military pay and fringe benefits are no longer comparable to the average employed civilian CRNA. The 2 starting salary difference between a military and civilian CRNA is between $10,000 and $45,000 per year, depending on time in the service and grade/rank. The AANA Membership Survey for Fiscal Year 1991 provided the following data for CRNAs mean gross annual salary/income by type of employment arrangement for calendar year 1989: Current active duty financial incentives for CRNAs include a $6,000 annual Incentive Special Pay (ISP) program. Current reserve financial incentives for some CRNAs include a $10,000 selected reserve recruitment bonus. While the above incentives help, the current $6,000 ISP for active duty CRNAs is insufficient to retain senior CRNA officers until at least 20 years. For example, the Army Nurse Corps is projected to be at 69 percent of authorized CRNA strength as of December 31, 1992, or 211 in the active duty inventory for 303 authorizations. Eleven of the losses for Fiscal Year 1992 are occurring between the 10th and the 19th year. In reality, increasing the CRNA ISP is much less expensive in the long run than contracting with civilian CRNAs for their services at a higher cost, which is becoming a new trend. In addition, the authority also exists for special pay for other military nurses in critical shortage areas of practice. The AANA wants to be supportive of our nursing colleagues also receiving special retention pay as warranted. Recommendations: 1. The $6,000 annual ISP for CRNA retention should be increased to $15,000 in order to be competitive with the civilian sector. Periodic examination of the effect of this bonus should be undertaken. 2. Other nurses in critical shortage areas of practice should also receive special pay as a retention tool. Promotion While the issue of giving constructive credit for nursing experience and advanced nursing education for purposes of initial grade appointment has improved, the slowness and limited potential for promotion is a major disincentive to remaining in the service. Promotion is not only a recognition of excellence, it is a pay issue as well. A significant number of CRNAs are considering leaving the military because of inadequate and inequitable promotions. 3 As congressionally requested, a 1991 report to the House and Senate Appropriations Committees was provided by DOD regarding the promotion policies of nonphysician health care providers. The AANA had provided recommendations to DOD on this matter that deal with the process of officer evaluations, criteria for promotion, and promotion board instruction, as well as with current grade constraints. We believe that an exemption from the Defense Officer Personnel Management Act (DOPMA) grade constraints for all corps within the military medical departments is the appropriate remedy to this problem. Recommendations: 1. 2. Exemption from the Defense Officer Personnel Management Act (DOPMA) grade constraints for all corps within the military medical departments. In addition, it is our understanding that the Army had requested RAND to study the aforementioned DOPMA exemption. The AANA would appreciate receiving a copy of the RAND report on this issue. Practice Issues A March 1989 report to Senator Daniel K. Inouye (D-HI) by the General Accounting Office entitled "DOD Health Care: Issues Involving Military Nurse Specialists" included information on CRNA concerns about their scope of practice in military hospitals and the degree of anesthesiologist supervision required. In April of 1990, the DOD submitted to the Senate and House Committees on Armed Services the congressionally mandated "Report on Military Use of Registered Nurse Anesthetists". The report described restrictions that DOD places on CRNAs. It noted that a 1983 DOD Directive 6025.2, "Nonphysician Health Care providers", that detailed requirements for physician supervision of CRNAs was rescinded in 1988. At the present time, the following three directives in the areas of quality assurance, licensure, and credentials provide the framework for health care policy in the DOD medical system: 1). DOD Directive 6025.13, "Medical Quality Assurance", 2). DOD Directive 6025.6, "Licensure of DOD Health Care Providers", and 3). DOD Directive 6025.11, "Health Care Provider Credentials Review and Clinical Privileging", which also specifies supervision and scope of practice requirements. The report notes that DOD policy does not require direct supervision of CRNAs by anesthesiologists, nor does it restrict CRNA practice to selected procedures. Rather, it authorizes hospital commanders to make decisions about the level of independent care provided in military treatment facilities. AANA is concerned that in reality this often results in unnecessary supervision practice restrictions placed on CRNAs, as well as limited opportunities to maintain advanced clinical skills. The report recognized that problems do exist by stating, "The Military Services have not revised CRNA guidelines to reflect current DOD policy as stated in DOD Directives 6025.11, 6025.13, and 6025.6. An effort to update policy, clarify scope of practice, and enhance communication must be undertaken to resolve nurse and physician concerns, many of which |