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January 1997
Volume 61 |
Number 1
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PRESIDENT'S PAGE
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| Preparing for
a New Millennium |
Phillip O. Bridenbaugh,
M.D., President
In my presentation to the ASA House of Delegates at the ASA Annual
Meeting in October, I made some general comments about the need
for all physicians to come together in preparation for the new
millennium we are about to enter. By virtue of being political
organizations, ASA and its component societies, like the federal
government and its state components, tend to function with short-term
issues and goals.
Failure to address major issues such as health care reform and
balanced budgets exemplifies the difficulty involved in elected
officials dealing with long-range planning. ASA, however, is embarking
on some significant areas of long-range planning that will require
the knowledge and input of its membership. More importantly, the
planning is not focused solely on legislative and economic issues
but on practice and education as well. I want to mention just
two areas that are of special interest to all of us, both of which
were referred to the Administrative Council for implementation.
Anesthesia Reimbursement
In response to actions of the House of Delegates, the Administrative
Council formed the Task Force on Procedure-Based Payment System
to be chaired by Orin F. Guidry, M.D. Ten ASA members representing
geographic, practice and subspecialty interests will serve on
this task force. As adopted by the Administrative Council, the
mission statement of the task force is as follows:
"The task force will review the various methods by which
anesthesiology services are currently reimbursed by selected geographically
diverse public and private third-party payers, with a particular
emphasis on the extent to which actual anesthesia time forms a
part of the reimbursement method. The task force will attempt
to quantify, nationally and regionally, the extent to which various
major reimbursement methods, e.g., fee-for-service, package-pricing
and capitation, are in use and the extent to which actual time
is accounted for in each category. The task force will attempt
to determine the impact - geographically and by major practice
characteristics, e.g., academic, private, personally performed,
anesthesia care team performed and subspecialty performed - of
the creation of a relative value guide that eliminates actual
time for some other modifier. Based on the foregoing, the task
force will offer its recommendations regarding the structure of
the ASA Relative Value Guide and whether changes should be recommended."
The decision to undertake this project has been suggested many
times in the past as more and more anesthesiologists have been
singled out as "different" from other physicians by
Medicare and other governmental payers. The advent of health care
reform some three to four years ago, espousing new payment methods
such as capitation, carve-out contracts, global fees, etc., has
shown the need for anesthesiologists to be knowledgeable about
other reimbursement methodologies besides the ASA Relative Value
Guide (base and time fee for service).
The ASA Committee on Economics has done an outstanding job of
keeping our Relative Value Guide updated on the value of existing
procedures as well as adding new anesthetic procedures to parallel
the growth of new surgical procedures. A more difficult task for
the committee has been the need for nonoperative anesthesia subspecialties
(e.g., pain management, critical care, obstetrics) to be included
in the Relative Value Guide. Many payers of obstetric services
find inclusion of time units for labor analgesia difficult to
budget and look to ASA for a consensus of practice. Even more
complex is the proper charge/ reimbursement for a labor epidural
converted to an emergency cesarean section. Practitioners of pain
management and critical care find their charges being compared
to those of other physicians providing (apparently) the same service.
It should be clear to all of us that we must first dethrone the
impact of locale, payer and type of practice on anesthesia reimbursement.
If we, as physician specialists, are to be included with our fellow
physicians in negotiating reimbursement from a variety of payer
groups (not just the federal and state governments), we must have
a similar methodology. If we continue to be singled out as "different,"
we may end up having our reimbursement negotiated by hospitals
or relegated to the nonphysician group as being a more "cost-effective"
service. I suspect nearly all physicians, particularly long-time
practitioners, want to preserve the current fee-for-service system
as long as possible. Maybe we can, but we also must make other
methodologies available for those payers and practitioners for
whom our current system is no longer workable and only penalizes
our practice rather than enhancing our reimbursement.
Evaluation of Structure and Governance
In December 1995, at the request of the ASA House of Delegates,
then President Norig Ellison, M.D., established the Ad Hoc Committee
on Executive Vice-President. The committee's charge was "to
evaluate the feasibility, desirability and alternatives to a full-time
Executive Vice-President." In addition to meeting as a group,
the committee sent letters seeking advice and counsel to the approximately
160 component society presidents and secretaries, directors and
alternate directors of the ASA Board of Directors. The committee
also surveyed 27 medical societies to obtain a sense of how many
societies have full-time physician executives (eight of 27) and
whom each society identifies as spokespersons and for what purposes.
Key senior AMA-elected and -employed officers were contacted,
and they provided the committee with the names of physician
executives. Substantial information was obtained from senior ASA
staff as well.
I believe the activities of this committee of five very respected
long-time ASA members, chaired by Harry H. Bird, M.D., reflected
a thoughtful, objective and thorough effort to provide ASA with
good advice. The recommendations of the committee were accepted
by the House of Delegates with referral to the Administrative
Council for implementation. In brief, the committee recommended
that:
"the Administrative Council, already charged with ASA's
planning responsibilities, oversee a long-range planning effort.
ASA should define its expectations and describe a Society most
likely to accomplish these expectations. Only then would it
be logical to propose specific changes in governance or structure."
A mistake many organizations make is to create or change their
structure and afterward attempt to determine what functions or
tasks that structure could or should undertake. One committee
member wisely noted that successful long-range planning should
not be an exercise to announce what ASA intends to do in
the future; rather, it should state what ASA needs to do now so
that we can determine the future we desire. The Administrative
Council will keep those comments in mind as it addresses this
important task.
The committee also acknowledged another pitfall in that long-range
planning exercises sometimes are not approached thoughtfully.
Often, the emphasis is on the word long, and the result
is a prolonged effort to draft a voluminous "white paper"
report full of difficult or unrealistic goals. Of course, the
antithesis of such an activity is a cursory look at the organization's
activities by a few insiders who decide quickly, "It isn't
broken, so it doesn't need fixing." What better argument
for preservation of the status quo?
An approach I might suggest we take would be analogous to the
type of preparations made before a lengthy expedition into an
area likely to present unknown challenges. The parties involved
would make a careful and thoughtful analysis of every detail of
the expedition's personnel, organizational assignments, leadership
surveillance and guidance as well as appropriate supplies and
administrative support.
ASA, along with all of organized medicine, is already embarking
on an expedition into the jungle of managed care and health care
reform. What better time for us to engage in a thoughtful planning
effort examining our existing structure and function to be certain
the former ideally serves the latter, rather than vice versa?
It took the U.S. Army a long time to realize that its old "TO
&Es," or Table of Organization and Equipment, needed
to be radically revised to adapt to the functions of strike forces
and small peacekeeping activities all over the world. We need
to be equally open-minded about preserving those areas of our
Society that are still very functional (and there are very many).
We must be ready to abandon the status quo for something better
if it will better serve our specialty. The federal government
has been illustrative of one of my favorite quotes - "Nothing
is a complete loss; it can always serve as a bad example"
- in that it has shown us repeatedly that politically motivated
decisions are not always in the best interest of their constituencies.
The Administrative Council plans to conduct a special meeting
devoted exclusively to discussing the implementation of the committee's
recommendation. Your thoughts and comments would be welcomed.
Feel free to contact me or any of ASA's officers with your thoughts.
You'll be making the expedition with us - let's do it right!
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