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August 1997
Volume 61 |
Number 8
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| Letters to the
Editor |
Position Statement on 'Change to a Single Conversion Factor'
Rather than view the single physician conversion factor of ±
$35 as an opportunity to fight for a return to fair reimbursement
and correction of a grievous error made by the Hsiao relative
value study regarding anesthesiology reimbursement, our leadership
has chosen to take a "please do not hurt us any more"
attitude. How pathetic! A conversion factor of ± $35 approximates
the "Maximal Allowable Actual Charge," the first restriction
placed on Medicare billing in 1989, which was met with little
resistance since it fairly approximated current reimbursement
rates. Now we beg to be reimbursed at half that rate? Are we complete
pushovers? Does our leadership dare to allow the general membership
input on this matter? This is the time to demand fair and reasonable
reimbursement for our professional services; $65 per hour is what
auto mechanics charge, not M.D.s. Shouldn't we take a stand? If
not now, when?
Stephen W. London, M.D.
Kahului, Hawaii
Mr. Scott Responds
Dr. London's letter exhibits a frustration with their level of
Medicare reimbursement felt by many ASA members. The fact is that
ASA expended a very large amount of time and money in 1995 and
1996 in connection with the congressionally mandated five-year
review of Medicare physician work values, attempting to correct
the "grievous error" made by William C. Hsiao, Ph.D.,
and his colleagues in valuing anesthesiology work. In the last
analysis, ASA succeeded in recouping for its members about half
the amount lost in 1992 as a result of the Hsiao study, and that
recoupment was reflected in the rather large increase in the anesthesiology
conversion factor this past January 1.
Anesthesiology can have a $35 (or thereabouts) Medicare conversion
factor any time it wants, simply by asking Congress to abandon
the "base units plus actual time units" method ASA successfully
fought to preserve for its members at the outset of the Medicare
Fee Schedule. Neither Congress nor the Administration would resist.
The result would be an approximate doubling of the conversion
factor to match all the other specialties, accompanied by a compensatory
dramatic decrease in the value of each unit of service to which
that conversion factor would be applied -- to jibe anesthesiology
reimbursement with the procedure-based RVU system now in use for
all other specialties.
The bottom line would be that the reimbursement for each type
of anesthesia procedure (e.g., 00540, anesthesia for thoracotomy
procedures) would be about the same on average, but for
each procedure, the reimbursement would be the same whether it
lasted one hour and 40 minutes to three hours and 10 minutes.
That's essentially what the Cambridge Health Economic Group (CHEG)
relative value guide, discussed by ASA President Phillip O. Bridenbaugh,
M.D., in recent letters to the membership, was designed to accomplish.
To date, neither ASA's officers, its Board nor its House of Delegates
has thought this was a good idea.
What Dr. London is advocating is a relative revaluation of anesthesiology
services against the services of all other physicians, so as to
raise Medicare reimbursement levels to what they were before the
Medicare Fee Schedule went into effect, or better. The recent
physician work exercise, in which both organized medicine and
the government fully participated, moved the specialty upward
in reimbursement relative to all other specialties, but not as
far as Dr. London and most anesthesiologists would like.
Since realistically this kind of Medicare exercise is always
going to be done on a budget-neutral basis, any gain for anesthesiology
will be every other specialty's loss. Under these circumstances,
it is not hard to imagine how difficult it would be to persuade
other specialties to give up even more reimbursement in favor
of anesthesiologists. In my personal judgment, ASA was fortunate
last year to convince the other specialties to give up as much
as they did, that is, $110 million a year in favor of the specialty,
and they would be downright hostile about giving up any more.
What ASA is now trying to do is defeat the President's proposal
that would in effect eliminate -- at one fell swoop like Lady
Macbeth's chickens -- the entire gain it so laboriously achieved
last year. This may be "pathetic," but it's going to
be a lot worse than pathetic, in the eyes of the ASA membership,
if the President has his way and ASA has done nothing to oppose
him.
According to Bismarck, politics is the art of the possible. In
1998, when the President and the GOP congressional leadership
have agreed to achieve $115 billion in Medicare savings over the
next five years, it will be difficult enough for ASA to persuade
Congress not to accept the President's proposal (itself worth
about $600 million in savings over five years) -- let alone seek
another increase, relative to the rest of medicine, hard on the
heels of its success last year.
Michael Scott, Director
Governmental and Legal Affairs
Consulting Is Essence of Specialty
I want to commend Jessie A. Leak, M.D., for her stimulating portrayal
of "The Anesthesiologist as a Consultant" [April 1997
NEWSLETTER]. The diverse role of the anesthesiologist has
evolved over the years and many of the activities that anesthesiologists
do today are appropriately called "consulting" as Dr.
Leak states "... the ability to synthesize a problem, design
a solution, confer with a client ... and effectively communicate
advisory summations or conclusions ..." She has suggested
additional opportunities for our specialty colleagues: in operating
room management, QA&I activities, managed care negotiations,
legislative lobbying and software development.
What is not emphasized, however, is that "consulting"
is precisely the role that most of us fulfill on a day-to-day
basis when providing surgical anesthesia as well as caring for
patients in labor and delivery, in critical care settings and
for postoperative and chronic pain management. In these settings,
we are consultants to other physicians, most often our surgical
colleagues, as well as to patients in a variety of medical circumstances.
We analyze a perioperative, critical care or other medical situation
and then render advice based on our education, training and experience.
I am fortunate that most of my surgical colleagues visualize my
role in that context.
The concept of the anesthesiologist as a "consultant"
in the operating room is the very essence of our specialty. It
is unfortunate that the Directors of the American Board of Anesthesiology,
as detailed by [ABA President] David E. Longnecker, M.D., in his
annual report last year, have decided no longer to refer to an
ABA diplomate as "consultant in anesthesiology." The
Board apparently feels that an anesthesiologist's skills should
"be described in terms of function, rather than type of practice."
I reacted negatively to this concept then and my feelings have
not changed. As a perioperative physician, I would like to think
of myself as something more than a functionary. Hopefully, the
ABA will reconsider its vision of the practicing anesthesiologist.
R. Lawrence Sullivan, Jr., M.D.
Palo Alto, California
The views and opinions expressed in the "Letters
to the Editor" are those of the authors and do not necessarily
reflect the views of ASA or the NEWSLETTER Editorial
Board. The Editor has the authority to accept or reject any
letter submitted for publication. Letters must be signed (although
name may be withheld on request) and are subject to editing
and abridgment.
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