March 2002
Volume 66 |
Number 3
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| Medicare
and the Anesthesia Shortage — Increasing Our Chances
for Survival |
ASA members recently received an urgent communication regarding
plans by the Center for Medicare & Medicaid Services to reduce
the Medicare Fee Schedule by 5.4 percent effective January 2002
and urging ASA members to contact their legislators to voice their
objection. The reaction of Massachusetts anesthesiologists who are
currently working in the midst of a severe statewide personnel shortage
may be different from anesthesiologists in other states, but it
also seems that our situation provides a preview of what is to come
in the rest of the country if the personnel shortage continues to
worsen. With those considerations in mind, it seems appropriate
to share the Massachusetts perspective.
The situation anesthesiologists in our state currently face makes
a 5.4-percent change in the Medicare physician fee schedule irrelevant.
That is not to imply that ASA should not bring such matters to
our attention. It seems, however, that complaining about a 5.4-percent
reduction in Medicare when current rates are already so egregiously
low is like worrying about a toaster fire in the kitchen when
the entire second story of the house is ablaze.
The personnel shortage in Massachusetts has reached a level that
is significantly impacting care in many community hospitals. We
increasingly hear from hospital administrators and anesthesiology
department chairs that their departments are on the verge of dissolving
as more and more anesthesiologists are lured away to other states
with a lower cost of living and higher reimbursement. A survey
of anesthesiology departments done by the Massachusetts Society
of Anesthesiologists confirms that group administrators are being
forced to triage the allocation of their resources as the number
of available anesthesia providers continues to decline. 1
Multihospital practices such as ours are under increasing pressure
to compete with higher salaries in other states, so we must maximize
our reimbursement. That means that hospitals with the lowest reimbursement
will be the first to lose services when there are no longer enough
providers. The same can be said of single-hospital groups: those
with the worst payer mix are likely to suffer first. Since Medicare
rates are currently 60 percent below commercial rates and dropping,
it is an inescapable conclusion that hospitals with large Medicare
populations are most likely to feel serious effects of the personnel
shortage first.
The Medicare Fee Schedule has been a problem for anesthesiology
since its implementation in the early 1990s. ASA has been working
through the American Medical Association/Specialty Society Relative
Value Update Committee (RUC) to make the case that Medicare reimbursement
was unfairly calculated and that anesthesiologists were disproportionately
hurt by the new fee schedule. That is a valid argument, but it
is important to understand that the problems with Medicare now
go well beyond the issue of fairness. The personnel shortage has
now turned it into an issue of access to care for seniors.
Anesthesiology groups in economically disadvantaged states such
as Massachusetts are faced with issues that necessitate hard decisions
about how to allocate their resources. Disgracefully low Medicare
rates are creating a situation in which hospitals with Medicare-heavy
populations are unable to sustain viable anesthesia groups without
making a sizable supporting payment of some type. However, many
of these hospitals are already in deficit-spending mode. As you
consider this problem, ask yourself what impact a 5.4-percent
change in Medicare would have on your decision to allocate personnel
if you did not have enough anesthesiologists to serve all of your
locations. Would it matter whether Medicare is 60 percent or 65
percent below commercial payers?
Those who live in states that have not yet felt the impact of
the personnel shortage may have empathy for our situation and
may be breathing a sigh of relief that they are not faced with
such decisions. If so, hold that sigh. Consider the fact that
Massachusetts is not the only state currently having this type
of problem and that the shortage is expected to worsen before
improving.
It is imperative that ASA members re-evaluate the amount of time
and money they spend being active in politics. The percentage
of anesthesiologists who contribute to the ASA Political Action
Committee is disgracefully low; the numbers that actually visit
their political representatives is even lower, and we are unlikely
to be successful in our efforts to improve our situation without
participating vigorously in the political process. If the blatant
unfairness of the Medicare Fee Schedule was not enough to motivate
anesthesiologists to take action in the political arena, then
please consider becoming active for the purpose of protecting
senior citizens’ access to anesthesia care in economically
disadvantaged states.
It also is important that ASA leadership consider a more aggressive
stance in its challenge of the Medicare Fee Schedule. A 150-percent
increase would be necessary to make Medicare rates comparable
to commercial rates, so it seems safe to say that something over
a 100-percent increase will be needed to make Medicare rates even
close to competitive for the increasingly limited anesthesia resources
available. Instead of trying to prevent a 5.4-percent decrease
in Medicare, ASA should be telling Congress that senior citizens’
access to anesthesia care in many states depends upon a significant
increase in the Medicare reimbursement rates for anesthesiologists.
The fact that this argument is politically difficult does not
make it any less true or just. If anesthesiologists choose to
avoid making this case because it seems they cannot win, they
admit to failure and forsake their role as patient advocates.
In the words of hockey great Wayne Gretzky, “You miss 100
percent of the shots you don’t take.”
Reference:
1. Eckhout G, Schubert A. Where have all the anesthesiologists
gone? Analysis of the national anesthesia worker shortage. ASA
Newsl. 2001; 65(4):16-19.
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Ross
J. Musumeci, M.D., is Vice-President, Anesthesia Associates
of Massachusetts, P.C., Westwood, Massachusetts.
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