FTC Staff Comment to the Honorable Heather A. Steans, Illinois State Senate, Concerning Illinois Senate Bill 1662 and the Regulation of Certified Registered Nurse Anesthetists (CRNAs)

Page 1 of 7
UNITED STATES OF AMERICA
FEDERAL TRADE COMMISSION
WASHINGTON, D.C. 20580
Office of Policy Planning
Bureau of Economics
Bureau of Competition
April 19, 2013
Hon. Heather A. Steans
Illinois State Senate
Room M120 – State Capitol Building
Springfield, IL 62706
Dear Senator Steans:
The staffs of the Federal Trade Commission Office of Policy Planning, Bureau of
Economics, and Bureau of Competition1 appreciate the opportunity to respond to your invitation
for comments on Illinois Senate Bill 1662 (“SB1662” or “the Bill”).2 The Bill provides that only
physicians may treat chronic pain through use of injections around the spine or spinal cord.
SB1662 may have significant implications for the provision of services by certified registered
nurse anesthetists (“CRNAs”), a type of advanced practice registered nurse with specialized
training in anesthesia and pain management and recognized under Illinois law. 3
Recent reports by the Institute of Medicine (“IOM”) have identified a key role for
advanced practice nurses – including CRNAs – in improving the delivery of health care. 4 The
IOM, established in 1970 as the health arm of the National Academy of Sciences, provides
expert advice to policy makers and the public and has conducted an intensive examination of
issues surrounding advanced nursing practice. 	Among other things, the IOM found that
“[r]estrictions on scope of practice . . . have undermined [nurses’] ability to provide and improve
both general and advanced care.”5 In a separate study examining pain as a public health
problem, the IOM found that regulatory barriers “limit the availability of pain care and
contribute to disparities found among some groups.” 6
Legislative testimony indicates that SB1662 would prohibit CRNAs from providing
treatments that they currently provide to patients.7 In some areas of Illinois, no alternative
providers, such as anesthesiologists or board-certified physician pain specialists, appear to be
available. Shortages of physicians in Illinois exist now and are projected to increase.8 By
restricting the provision of services by CRNAs, the Bill may impede price and non-price
competition among providers of pain management services and increase costs to Illinois citizens,
the State of Illinois, and other third-party payers. It may also exacerbate problems of access to
care, especially for rural and other underserved populations.
For these reasons, we recommend that the Illinois Senate carefully examine whether the
broad prohibition in SB1662 is necessary for patient safety. We recognize that patient health and
safety concerns are of critical importance when states regulate the scope of practice of health

Page 2 of 7
care professionals, and FTC staff express no opinion on the ultimate health and safety standards
or scope of practice restrictions that the Illinois legislature may choose to establish. We do,
however, recommend that in considering the Bill, you seek to ensure that any limits on CRNAs
are no stricter than patient protection requires. In particular, we recommend that you investigate
whether there is evidence that current CRNA practice is harmful to patients and, if so, whether
the Bill is tailored to address health and safety concerns based on those demonstrated harms.
Given the Bill’s potential negative effects, avoiding unwarranted restrictions on CRNA practice
can offer significant benefits to the provision of health care in Illinois.
I. 	Interest and Experience of the Federal Trade Commission
The FTC is charged under the FTC Act with preventing unfair methods of competition
and unfair or deceptive acts or practices in or affecting commerce.9 Competition is at the core of
America's economy, 10 and vigorous competition among sellers in an open marketplace gives
consumers the benefits of lower prices, higher quality products and services, more choices, and
greater innovation. Because of the importance of health care competition to the economy and
consumer welfare, anticompetitive conduct in health care markets has long been a key target of
FTC law enforcement, 11 research,12 and advocacy.13 Recently, FTC staff has analyzed the likely
competitive effects of proposed regulations relating to CRNA and advanced practice registered
nurse (“APRN”) practice in other states.14
II. 	Senate Bill 1662
SB1662 would prohibit CRNAs from providing patients with interventional chronic pain
management, with or without the aid of imaging technology. The Bill generally prohibits anyone
from using interventional procedures to either diagnose or treat chronic pain in Illinois “unless
the person is a physician licensed to practice medicine in all its branches.”15 Although the Bill
would permit APRNs – including CRNAs – to assist physicians, it would prohibit attending
physicians from delegating any of the prohibited interventional pain procedures to licensed
CRNAs. 16
The Bill’s list of prohibited treatments appears to encompass a broad range of services,
including some currently provided by CRNAs, consistent with their training and national
certification.17 Stakeholders have expressed concern, for example, that prohibited procedures
would include commonly used types of epidural injections in any region of the spine, “with or
without imaging guidance.”18 The Bill would categorically prohibit CRNAs from administering
such treatments for chronic pain, regardless of the CRNA’s training, licensure, and experience,
and regardless of physician participation in other aspects of a patient’s diagnosis or treatment.
Indeed, by imposing a blanket prohibition on the provision of these services by CRNAs, the Bill
appears to eliminate the ability of physicians, other care team members to make patient-specific
decisions regarding the optimal allocation of responsibilities and tasks.
III. 	Likely Costs and Benefits of SB1662
We recognize that certain professional licensure requirements are necessary to protect
patients.19 In particular, special practice requirements or other restrictions may be recommended

Page 3 of 7
or required for certain chronic pain indications or treatments that may present heightened
consumer risks. In light of concerns about the Bill’s likely competitive impact, however, we
urge careful scrutiny of the need for SB1662.
a. 	The Bill Raises Significant Competitive Concerns
The breadth of the limitations in SB1662 threatens a variety of competitive harms. First,
by limiting the supply of health care professionals who can provide the covered pain treatments,
it appears likely to exacerbate health care access problems. An IOM report on pain and pain
treatment observes that under-treatment of chronic pain is widespread, and that “undertreatment
generates enormous costs to the [health care] system and to the nation’s economy.”20 The same
report notes that, “chronic pain rates are likely to continue to rise,” 21 and suggests that the
general population of primary care physicians, as well as some specialist physicians, may be
undertrained and inexperienced in best pain management practices.22 Access problems may be
particularly acute in rural areas, where alternative providers of pain management services appear
to be in short supply.23 As noted above, many areas in Illinois already are subject to shortages of
both primary care and specialist physicians,24 and CRNA practices disproportionately serve rural
patients.25
The Bill’s effects would likely be felt most acutely by Illinois’ most vulnerable
populations – the elderly, the disadvantaged, and rural citizens. As the IOM pain report notes,
“pain is more prevalent and less likely to be adequately treated in certain population groups,
including the elderly, women, children, and racial and ethnic minorities.”26 The same report
notes that, nationally, rural areas face particular shortages of pain care specialists,27 even though
aspects of rural life may increase the likelihood of injuries requiring pain treatment.28 Based on
recent reports, numerous Illinois counties appear to have zero specialized providers of anesthesia
or pain care, and in more than two dozen counties CRNAs are the only such licensed providers.29
In addition, SB1662 may reduce competition on price, convenience, and quality among
remaining providers. By limiting the ability of CRNAs to provide chronic pain management
services, the Bill likely will reduce the competitive pressures – and constraints – on practitioners
and facilities that remain able to offer pain treatment. Higher out-of-pocket prices, more limited
hours, and reduced distribution of services throughout the state all may tend to reduce access to
pain treatment. Higher prices, in particular, may force difficult choices on some Illinois health
care consumers who rely on relief from chronic pain to go about their daily lives. As an article
in Health Affairs noted, “when costs are high, people who cannot afford something find
substitutes or do without.”30
Finally, the Bill may reduce innovation in health care delivery. Restrictions on CRNAs
may limit not only physician-CRNA collaborations, but also the ability of health care providers
to develop, test, and implement the most efficient teams of pain management professionals. For
example, under SB1662, attending or supervisory physicians could not delegate the
administration of a restricted procedure to a non-physician professional.31 The Bill’s restrictions
also may impede CRNA access to training opportunities, especially as standards of care for
chronic pain treatments evolve.

Page 4 of 7
b. 	Legislative Consideration of Health and Safety Issues
FTC staff urge legislators to carefully consider whether there is evidence to justify the
broad restriction on CRNA practice that SB1662 would impose. We urge the legislature to
consult with experts in nursing and medicine and to rely upon other pertinent information to
clarify various technical matters. We also encourage the legislature to consider the nature of
current chronic pain treatment practice in Illinois and consider available empirical and other
evidence that may bear on patient safety issues, including relevant IOM reports.32
If the legislature finds that regulation is warranted—for example, with respect to
particular procedures or indications—we recommend that the legislature consider how best to
tailor provisions and restrict CRNA practice only to the extent required to ensure patient safety.33
In this circumstance, the legislature may wish to consider a more flexible regulatory approach,
rather than the categorical statutory limits proposed in SB1662. Appropriate regulations may
more readily be recalibrated over time, as the scientific understanding of chronic pain and pain
therapy progresses, and may more readily take into account such developments and more easily
target particular risks.34
Conclusion
In our view, SB1662 threatens to raise costs, limit access, and reduce choices for Illinois
patients. We therefore recommend that the Senate carefully investigate patient safety issues and
ensure that any statutory limits on CRNAs are no stricter than patient safety requires.
We appreciate your consideration of these issues.
Respectfully submitted,
Andrew I. Gavil, Director
Office of Policy Planning
Howard Shelanski, Director
Bureau of Economics
Richard A. Feinstein, Director
Bureau of Competition

Page 5 of 7
1 This letter expresses the views of the Federal Trade Commission's Office of Policy Planning, Bureau of
Economics, and Bureau of Competition. The letter does not necessarily represent the views of the Federal Trade
Commission (“Commission”) or of any individual Commissioner. The Commission has, however, voted to authorize
us to submit these comments.
2 Letter from Hon. Heather A. Steans, Illinois Senate, to Andrew I. Gavil, Director, FTC Office of Policy Planning
(Feb. 25, 2013).
3 Ill. Comp. Stat. Art. 65 § 65-5(b), (b-5).
4 See generally I NSTITUTE OF MEDICINE, THE F UTURE OF N URSING : LEADING CHANGE, A DVANCING H EALTH (2011)
[hereinafter IOM N URSING R EPORT ] (especially Summary, 1-15).
5 Id. at 4.
6 I NSTITUTE OF MEDICINE, COMMITTEE ON A DVANCING P AIN RESEARCH, CARE, AND EDUCATION , R ELIEVING P AIN IN
A MERICA: A BLUEPRINT FOR TRANSFORMING P REVENTION , CARE, EDUCATION , AND RESEARCH 2, 80, 157 (2011)
[hereinafter IOM P AIN REPORT].
7 Staff have received input regarding CRNA practice and training in Illinois from, e.g., Draft Testimony of Rev.
Jeremiah Loch, CRNA, Illinois Association of Nurse Anesthetists Before the Senate Licensed Activities & Pensions
Committee RE: Senate Bill 1662 (Apr. 2013).
8 See, e.g., U.S. D EPARTMENT OF H EALTH AND H UMAN S ERVICES , H EALTH RESOURCES AND S ERVICES
A DMINISTRATION BUREAU OF H EALTH P ROFESSIONS , THE P HYSICIAN W ORKFORCE: P ROJECTIONS AND R ESEARCH
INTO CURRENT I SSUES A FFECTING S UPPLY AND D EMAND 70 (2008) [hereinafter HRSA PHYSICIAN W ORKFORCE
REPORT ]; id. at 70-72, exhibits 51-52.
9 Federal Trade Commission Act, 15 U.S.C. § 45.
10 Standard Oil Co. v. Federal Trade Commission, 340 U.S. 231, 248 (1951) (“The heart of our national economic
policy long has been faith in the value of competition.”).
11 See generally, e.g., Fed. Trade Comm’n, An Overview of FTC Antitrust Actions In Health Care Services and
Products (March. 2013), available at t http://www.ftc.gov/bc/healthcare/antitrust/hcupdate.pdf; see also FTC,
Competition in the Health Care Marketplace: Formal Commission Actions, available at
http://www.ftc.gov/bc/healthcare/antitrust/commissionactions.htm.
12 See, e.g., FTC & U.S. D EP ’ T OF J USTICE (“DOJ”), I MPROVING H EALTH C ARE: A D OSE OF COMPETITION (2004),
available at http://www.ftc.gov/reports/healthcare/040723healthcarerpt.pdf [hereinafter FTC & DOJ, I MPROVING
H EALTH CARE ].
13 FTC and staff advocacy may comprise letters or comments addressing specific policy issues, Commission or staff
testimony before legislative or regulatory bodies, amicus briefs, or reports. See, e.g., Letter from FTC Staff to Hon.
Timothy Burns, Louisiana Legislature (May 1, 2009) (regarding proposed restrictions on mobile dentistry),
available at http://www.ftc.gov/os/2009/05/V090009louisianadentistry.pdf; FTC and DOJ Written Testimony before
the Illinois Task Force on Health Planning Reform Concerning Illinois Certificate of Need Laws (Sept. 2008),
available at http://www.ftc.gov/os/2008/09/V080018illconlaws.pdf; FTC Amicus Curiae Brief in In re
Ciprofloxacin Hydrochloride Antitrust Litigation Concerning Drug Patent Settlements Before the Court of Appeals
for the Federal Circuit (Case No. 2008-1097) (Jan. 2008), available at
http://www.ftc.gov/os/2008/01/080129cipro.pdf; FTC & DOJ, I MPROVING H EALTH C ARE, supra note 11.

Page 6 of 7
14 See FTC Staff Letter to the Hon. Jeanne Kirkton, Missouri House of Representatives, Concerning Missouri House
Bill 1399 and the Regulation of Certified Registered Nurse Anesthetists (March 2012), available at
http://www.ftc.gov/os/2012/03/120327kirktonmissouriletter.pdf; FTC Staff Letter to the Honorable Gary Odom,
Tennessee House of Representatives, Concerning Tennessee House Bill 1896 (H.B. 1896) and the Regulation of
Providers of Interventional Pain Management Services (Sept. 2011), available at
http://www.ftc.gov/os/2011/10/V11001tennesseebill.pdf; FTC Staff Letter to the Hon. Rodney Ellis and the Hon.
Royce West, the Senate of the State of Texas, Concerning Texas Senate Bills 1260 and 1339 and the Regulation of
Advanced Practice Registered Nurses (May 2011), available at
http://www.ftc.gov/os/2011/05/V110007texasaprn.pdf; FTC Staff Letter To The Hon. Daphne Campbell, Florida
House of Representatives, Concerning Florida House Bill 4103 and the Regulation of Advanced Registered Nurse
Practitioners (Mar. 2011), available at http://www.ftc.gov/os/2011/03/V110004campbell-florida.pdf; FTC Staff
Comment Before the Alabama State Board of Medical Examiners Concerning the Proposed Regulation of
Interventional Pain Management Services (Nov. 2010), available at
http://www.ftc.gov/os/2010/11/101109alabamabrdme.pdf.
15 SB1662, Ill. 98 th Gen. Assembly, § 10.
16 Id.
17 National certification of CRNAs is administered by the National Board on Certification and Recertification of
Nurse Anesthetists (“NBCRNA”), which determines eligibility requirements for the certification exam, and
formulates and administers the National Certification Exam for CRNAs. See, e.g., National Board on Certification
and Recertification of Nurse Anesthetists, Certification, available at
http://www.nbcrna.com/cert/Pages/default.aspx; see also NBCRNA, 120 th National Certification Examination
(NCE) Candidate Handbook (2013), available at
http://www.nbcrna.com/certification/Documents/2013%20NCE%20Candidate%20Handbook%20v3.pdf; IOM
N URSING R EPORT, supra note 4, at 41 (CRNAs “[a]dminister anesthesia and provide related care before and after
surgical, therapeutic, diagnostic, and obstetrical procedures, as well as pain management.”).
18 SB1662, Ill. 98 th Gen. Assembly, § 5(4). Regarding CRNA practice and training in Illinois, see supra note 7;
Interview with Paul Darr, Southern Illinois Univ. School of Nursing (Apr. 9, 2013).
19 For example, licensure requirements or scope of practice restrictions may sometimes offer an efficient response to
certain types of market failure arising in professional services markets. See CAROLYN C OX & S USAN F OSTER ,
F EDERAL TRADE C OMMISSION, BUREAU OF ECONOMICS , THE C OSTS AND BENEFITS OF O CCUPATIONAL REGULATION
5-6 (1990), available at http://www.ftc.govibe/consumerbehavior/docs/reports/CoxFoster90.pdf.
20 IOM P AIN REPORT, supra note 6, at 153. For a more detailed discussion of the scope of the problem and its
associated costs, see generally id. at C.2, 55-103..
21 Id. at 62.
22 Id. at 154-6.
23 See, e.g., IOM N URSING REPORT, supra note 4, at 107-09, 112 (regarding physician shortages in rural and other
underserved areas).
24 See supra note 8 and accompanying text. Although FTC staff have not surveyed pain specialist distribution in
Illinois county-by-county, we note that testimony regarding a neighboring state, Missouri, indicated that CRNAs
were the only licensed specialist providers of anesthesia services in 31 of the state’s counties. FTC Staff Letter to
the Hon. Jeanne Kirkton, Missouri House of Representatives, Concerning Missouri House Bill 1399 and the
Regulation of Certified Registered Nurse Anesthetists, note 23 and accompanying text (Mar. 2012), available at
http://www.ftc.gov/os/2012/03/120327kirktonmissouriletter.pdf.
25 See, e.g., Brian Dulisse & Jerry Cromwell, No Harm Found When Nurse Anesthetists Work Without Supervision
by Physicians, 29 H EALTH A FFAIRS 1469, 1469 (2010) (CRNAs “provide thirty million anesthetics annually in the
United States and represent two-thirds of anesthetists in rural hospitals.”); cf. J.P. Abenstein & Mark A. Warner,
Anesthesia Providers, Patient Outcomes, and Costs, 82 A NESTHESIA & A NALGESIA 1273, 1279 (1996) (nurse
anesthetist-only practices found predominantly in smaller, rural hospitals).

Page 7 of 7
26 IOM P AIN REPORT, supra note 6, at 48.
27 Id. at 80, 157.
28 Id. at 80.
29 Am. Ass’n of Nurse Anesthetists, Distribution of Illinois Anesthesia Providers (Oct. 2011) (map and county-level
table based on AMA master file and reporting to U.S. Dep’t Health and Human Servs., HRSA).
30 William Sage, David A. Hyman & Warren Greenburg, Why Competition Law Matters to Health Care Quality, 22
H EALTH A FFAIRS 31, 35 (Mar./Apr. 2003). Although estimates of the elasticity of demand for health insurance
coverage vary, the empirical evidence is clear that higher costs result in less coverage. See D AVID M. C UTLER ,
H EALTH CARE AND THE P UBLIC S ECTOR , National Bureau of Economic Research Working Paper W8802, Table 5
(Feb. 2002), available at http://papers.nber.org/papers/W8802.
31 SB1662, Ill. 98 th Gen. Assembly, § 10.
32 See, e.g., IOM N URSING REPORT, supra note 4, at 111 (citing diverse evidence, including Dulisse & Cromwell,
supra note 25, in concluding that CRNAs provide high-quality care, with no evidence of patient harm, with respect
to anesthesia and acute services).
33 See, e.g. id. (with respect to CRNA provision of anesthesia and acute services, Dulisse & Cromwell “found no
increase in patient mortality or complications in states that opted out of the [Centers for Medicare and Medicaid
Services] requirement that an anesthesiologist or surgeon oversee the administration of anesthesia by a CRNA.”).
34 Another potential advantage of a regulatory approach is that the regulatory process would facilitate full
participation by all stakeholders with an interest in the safe, effective, and efficient delivery of pain management
services, including physicians, CRNAs, hospitals, and others.