Anesthesia's 2027 Medicare Math: A Falling Conversion Factor, a 22.5% Cost Increase, and Three Roles on Different Lines of the Same Table

The comment period on Medicare's CY 2027 Physician Fee Schedule proposed rule closed on September 14, 2026, and the final rule is expected on or around November 1 with policies effective January 1, 2027 (ASA). For anesthesia, the proposal reverses the single year of relief the specialty received in 2026.

The headline percentages look small. The cumulative picture, and the way the rule distributes its effects across anesthesiologists, CRNAs, and certified anesthesiologist assistants, is what matters for 2027 staffing budgets.

What is the proposed 2027 Medicare anesthesia conversion factor?

CMS proposed an anesthesia conversion factor of $20.4165 for qualifying APM participants and $20.2143 for non-qualifying participants in CY 2027, down from $20.5998 and $20.4976 respectively in CY 2026 (ASA).

The anesthesia conversion factors carry an adjustment the general fee schedule does not. Beyond statutory updates and the budget neutrality adjustment, the proposed anesthesia conversion factors include a 0.30% specialty-specific practice expense and malpractice adjustment (Holland & Knight).

The decrease is mostly a cliff rather than a policy choice. ASA attributes the drop largely to the expiration of the 2.5% physician payment increase authorized for CY 2026, and CMS states that the one-year 2.5% increase "will no longer be in effect for CY 2027," which "effectively means that current law requires -2.50% reduction in Medicare payment under the PFS compared to CY 2026" (CMS).

Conversion factor	2019	CY 2026	Proposed CY 2027	Change since 2019
Anesthesia, qualifying APM	$22.2730	$20.5998	$20.4165	-8.3%
Anesthesia, non-qualifying APM	Not stated	$20.4976	$20.2143	-9.2%
General PFS, qualifying APM	Not stated	$33.5675	$33.1693	-1.19% vs 2026
General PFS, non-qualifying APM	Not stated	$33.4009	$32.8409	-1.68% vs 2026
Medicare Economic Index, 2020 through est. CY 2027	—	—	—	+22.50%

Why is anesthesia losing ground even though the proposed cut looks small?

Anesthesia is losing ground because a roughly 1% annual decline compounds against input costs rising four times faster. AANA's comment letter states that the proposed CY 2027 qualifying APM anesthesia conversion factor of $20.4165 "has decreased by 8.3% since 2019, when it was $22.2730," that the non-qualifying conversion factor has decreased 9.2% over the same period, and that "the Medicare Economic Index (MEI) from 2020 through CY 2027 (estimated) has increased by a cumulative 22.50%" (AANA).

That spread is the arithmetic behind the stipend economy. When Medicare's anesthesia unit price falls in nominal terms while wages, malpractice premiums and recruiting costs rise, the gap has to be funded by someone, and increasingly that someone is the hospital or ASC — the dynamic covered in this earlier post on the 2026 stipend boom.

The two-conversion-factor structure adds a second, quieter penalty. MACRA provides a 0.75% base update for qualifying APM participants and only 0.25% for everyone else, and ASA notes bluntly that "most anesthesiologists do not qualify for the higher base payment update" (ASA). AANA makes the parallel point for nurse anesthetists, warning that the decline "will continue to grow more acute for CRNAs who do not have adequate opportunities to participate as Qualifying APM Participants" (AANA).

Does the rule treat anesthesiologists, CRNAs, and CAAs differently?

Yes, and the specialty impact estimates move in three different directions. CMS estimates the combined effect of proposed work, practice expense and malpractice RVU changes at 0% for anesthesiology on $1,656 million in allowed charges, +1% for the "Nurse Anesthetist/Anesthesiologist Assistant" category on $1,130 million in allowed charges, and -2% for interventional pain management on $880 million in allowed charges (ASA).

Those estimates exclude the conversion factor changes. ASA notes that "statutory across-the-board updates to the CF are not reflected in the impact table," so a nurse anesthetist line showing +1% from RVU changes still absorbs the conversion factor decline on top of it.

The single biggest structural detail for care team planning is the category name itself: CMS reports nurse anesthetists and anesthesiologist assistants as one combined specialty line, which means certified anesthesiologist assistants have no separate federal payment impact estimate in the proposed rule at all.

What is the American Society of Anesthesiologists asking CMS to change?

ASA's September 14 comment letter opposes a 50% payment cut for services reported with Modifier 25 and asks for at least a one-year delay of the Ambulatory Specialty Model set to launch in January (Becker's ASC).

The underlying proposal reduces payment when a clinician bills a separately identifiable office or outpatient E/M visit on the same day as a 0-, 10- or 90-day global procedure, paying the most expensive service at 100% and the other at 50%, and CMS is seeking comment on whether to extend it to inpatient E/M visits as well (ECG Management Consultants). That proposal lands hardest on interventional pain practices, which is consistent with the -2% impact estimate for that specialty.

ASA also said the proposed conversion factor update "falls short of keeping pace with rising practice costs, workforce expenses and inflation," opposed eliminating two anesthesia-specific quality measures covering prevention of postoperative nausea and vomiting, asked for greater transparency around the anesthesia-specific practice expense and malpractice adjustments, and asked CMS to recognize anesthesia physical status modifiers in the same manner as other complexity modifiers (Becker's ASC).

What is AANA asking for on behalf of CRNAs?

AANA, writing on behalf of more than 71,000 members, asked CMS to work with Congress on Medicare payment reform rather than treating the annual conversion factor as the fix (AANA).

AANA's specific requests are narrower than its rhetoric. The letter asks CMS to ensure all Part B providers can meaningfully participate in Alternative Payment Models, to maintain an XXX global period for CPT codes 01953, 01968 and 01969, to support a more transparent CPT Editorial Panel and RUC valuation process, and to maintain clinically relevant anesthesia measures in the Quality Payment Program (AANA).

CRNA payment exposure under Medicare differs structurally from the commercial market. AANA states that CRNAs "have been Medicare Part B providers since 1989, billing Medicare directly at 100% of the Physician Fee Schedule," so the anesthesia conversion factor flows through to CRNA billing at full rate — while on the commercial side, UnitedHealthcare's 15% cut to CRNA reimbursement is what AANA president Tracy Young, CRNA, identified as a sustainability threat passed through to hospitals (Becker's ASC).

Where do certified anesthesiologist assistants fit in the 2027 rule?

Certified anesthesiologist assistants appear in the proposed rule only inside a combined specialty category with nurse anesthetists, which means CAA-specific payment effects cannot be read out of the federal impact tables. CAA economics in 2027 will therefore be set by two things the rule does not address: the anesthesia conversion factor that flows through the care team's billing, and state authorization.

State authorization is where CAA capacity is actually moving. Tennessee's governor signed CAA licensure in May 2025, Virginia granted CAAs authority to practice alongside physician-led anesthesia teams in March 2025 with legislation effective that July, Kansas legislators introduced a licensing bill, California legislators introduced an authorizing bill in April 2025, and Kansas City University opened admissions for a Master of Health Science in Anesthesiologist Assistant program launching in January 2026 (Becker's ASC).

For hospital and ASC leaders, the practical consequence is that a CAA-inclusive staffing model is a state-by-state question with no federal payment signal attached, while a CRNA-inclusive model carries a federal payment signal that is declining.

What does the 2027 rule mean for staffing budgets?

It means the labor market and the payment schedule are moving in opposite directions for the third consecutive planning cycle. Anesthesiologists received average sign-on bonuses of $59,583 in 2024-2025, more than 50% above the $38,215 average across all physician specialties, with anesthesiology the third most-requested physician search nationally and average starting salaries reaching $485,000, up 5.5% year over year, per AMN Healthcare's 2025 recruiting incentives review (Becker's ASC).

CRNA recruiting costs are following the same curve. New-graduate CRNAs were offered average sign-on bonuses of $40,000 plus a $5,000 relocation bonus, and 80% of CRNAs received a sign-on bonus offer averaging around $20,000 (Becker's ASC).

Budget the 2027 anesthesia line on the assumption that professional fee revenue per unit is flat to slightly down while the cost per clinician rises by mid single digits. For groups building or defending a subsidy request this fall, the AANA conversion factor series and the MEI comparison are the cleanest public evidence available, and the methodology caveats around any compensation benchmark used in that request are covered in this post on anesthesia compensation surveys.

A note on the data

Everything above describes a proposed rule, not final policy; CMS may change any of it in the final rule expected on or around November 1, 2026. The two associations published slightly different percentages for the same conversion factor change: ASA reported the qualifying APM anesthesia conversion factor falling 0.88% while AANA and Ventra Health reported 0.89%, and the CY 2026 to CY 2027 figures published by ASA compute to approximately 0.89%, so the difference is rounding rather than disagreement about the dollar amounts. The one-year 2.5% CY 2026 increase is named differently across sources, appearing as the One Big Beautiful Bill Act in ASA's alert and as the Working Families Tax Cut legislation, Public Law 119-21, in CMS's fact sheet. The specialty impact estimates come from CMS Table D-B5 as reported by ASA and exclude statutory conversion factor updates, so they understate the total effect on any given practice, and CMS itself notes impact "will vary based on service mix." The CAA legislative items are 2025-vintage actions reported in 2026 and several bills remained pending rather than enacted. Recruiting figures come from a staffing firm's incentives review rather than a neutral survey.