Ep 170: The History of TEFRA and How It Changed Anesthesia

Forty years have passed since the Tax, Equity and Fiscal Responsibility Act (TEFRA) became law and this piece of federal legislation changed the way payment and reimbursement was tracked. Today we’ll look back on the history of TEFRA with Nancy Bruton-Maree, CRNA, and Sandy Ouellette, CRNA, to learn more about the reasons behind it, how the AANA responded, and what revisions have been made through the years.

Click the timestamps below to help you navigate through the many topics we discussed.

On This Episode:

Back in 1982, the Tax, Equity, and Fiscal Responsibility Act (TEFRA) was enacted into federal law and changed the way payment was tracked and processed for everyone in anesthesia. It was an important piece of federal legislation then and it’s no different today.

Now that 40 years have passed, we thought it would be helpful to go back and learn more about the history of TEFRA. Why did the government feel this was a necessary law? What were the major concerns at the time? How has it evolved over time as revisions were made?

To help us answer all of these questions, we asked our resident historians Nancy Bruton-Maree, CRNA, and Sandy Ouellette, CRNA, to come back on with us. They remember what it was like before TEFRA and what changed after it was passed, and we’ll hear their perspective on the show.

As you get started on the episode, keep an ear out for these topics:

  • The reasons behind the act being created and implemented.
  • Why reimbursement was the basis for this but why do so many people consider it quality of care issue?
  • Sandy and Nancy share stories from practicing anesthesia before TEFRA.
  • What the original rules said and why they came up with the ratios they did.
  • The difference between medical direction and medical supervision.
  • An explanation of the 7 conditions of payment
  • What the AANA thought about TEFRA and the concerns that arose in the 1990s.
  • It’s important to know the current rules of TEFRA and how it impacts you.

We also wanted to mention that we’ve gotten so much great feedback about this historical series and we thank you for that. If you ever want to connect with Sandy or Nancy to ask them a question or request a subject for the podcast, you can email them at nbmaree@gmail.com and souellette515@gmail.com.

Check it out the interview at the top of the page and use the timestamps to help you navigate through the many topics we discussed.

3:00 – What we’re talking about today

5:05 – Why was TEFRA implemented?

8:04 – Quality of care standard

9:33 – What the practice used to look like?

14:27 – Preparing practitioners

15:36 – What the original rules said

20:32 – Medical supervision and direction

26:56 – 7 conditions of payment

28:49 – AANA’s reaction to TEFRA

31:23 – Concerns between 1993 to 1998

34:32 – Proposed revisions

37:45 – What is immediately available

40:44 – Current TEFRA rules

44:20 – Any updated revisions?

47:15 – Physicians starting schools

51:15 – A book recommendation

52:02 – Final thoughts


“There was a concern and a need to ensure that anesthesiologists showed that they provided certain services as part of an anesthetic to qualify for payment of medical direction of the CRNA. I guess that’s much easier to say than fraud. There was a lot of fraud out there then.”

-Sandy Ouellette





CRNA Careers

Balancing a Career in Music with Being a CRNA

In this episode, Sharon and guest host Tracy Castleman, DNP, CRNA, APN-A, FAANA sit down David Giardinelli-O’Connor, PhD, DNAP, CRNA, who has successfully balanced a demanding career in anesthesia with his lifelong passion for music.




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J. Cross CRNA
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