May 2002
Volume 66 |
Number 5
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| Letters
To The Editor |
Sacrificial Lamb or Egregious Ham?
For years I have enjoyed your wisdom and eloquence, first
in the New York Sphere journal and now with ASA. With your
editorial on September 11, I was touched to see that here
was a warm-blooded human being, too. It was with some dismay
that I saw your critics attempt to sacrifice you on the
altar of political correctness. More power to you! Too often
as physicians we become detached to the impoverishment of
our emotional and spiritual selves. Never mind the snow
trivia, keep going as you always have. Mind you, I think
your efforts to have us dress better, though laudable, are
fighting a rear-guard action.
I have enclosed an example of egregious political incorrectness
that I have treasured and been heartened by for years.
Anesthesiologist's Prayer
Please bless these hands and this mind, O Lord, that they
may safely care for those entrusted to them this day. Keep
my hands agile, my mind acute and my eyes sharp, that no
anesthetic misadventure may befall my patients. Though they
are in my hands, my hands are in thine, O Lord, please guide
them well. Amen.
– J.G. Converse, M.D.
Juliet M. Gill, M.D.
Ingleside, Ontario, Canada
Editor's
Note – For those who are not atheistic or agnostic,
this universal prayer helps one to focus on the tasks and talents
necessary for ensuring a safe medical outcome. It is a well-known
verse that the last generation of anesthesiologists have undoubtedly
seen.
–
M.J.L.
Armageddon
Comes to New York
As I was pulling into the parking lot of a plastic surgeon's
office on a sunny Tuesday morning, my telephone rang, and
my business partner told me armageddon had struck. It was
September 11, 2001.
I contacted the Federal Emergency Management Agency, and
they told me that boats were leaving from Long Island. After
my cases, I headed to the dock. While waiting for boats
to arrive, I helped set up a M.A.S.H. unit and makeshift
morgue. As dusk approached, I got word that no boat would
be arriving and that the morgue and M.A.S.H. units were
being powered down.
A 100-bay M.A.S.H.-style unit was being set up about a
mile from ground zero at the Chelsea Pier. I heard they
were expecting to care for 500 injured police and fire workers
and were in need of anesthesiologists. Once there, minutes
turned into hours, and it became clear that a mass of injured
people were not going to be arriving.
Undeterred, an anesthesiologist friend and I accepted a
ride from a police officer toward the epicenter of the disaster.
The first thing I noticed was the thick air. Beneath our
feet were several inches of ash and papers – half-burned
claim forms from Blue Cross, charred pen caps and financial
statements with notations made with fresh ink. The foreground
was a heap of twisted metal with a procession of firefighters
and emergency workers. Like soldiers in the Army, their
dirty, weary and sad faces told a story of a battle with
unknown outcome.
Our destination revealed a row of empty beds and a few
medical personnel standing by idly. There were no survivors
to help! It seemed as though whoever was fortunate enough
to get out did so with minor injuries and whoever did not
had perished in the amalgam of twisted steel, concrete and
debris.
I arrived home just before sunrise, exhausted, covered
in ash and smelling of noxious chemicals. I had barely enough
strength to throw myself onto the couch. Drifting off, I
felt proud that I had the courage to serve as best I could
and only wished there were more people we could have helped.
Marc E. Koch, M.D.
New Rochelle, New York
Reader
Gets 'Kick' Out of Dr. Lema
Just a note
that I heartily agree with the letter by Gehl H. Davis, M.D.,
in the February issue. No need to be apologetic or disheartened.
The editorial page is yours alone to write your opinions. If they
don't like it, they can get someone else.
As Gerald
L. Zeitlin, M.D., said in the same issue, if nothing else, the
membership is now reading it with greater interest and thinking
about what's written. Lord knows most anesthesiologists need a
kick in the pants to get them thinking off the beaten track.
Leo I. Stemp,
M.D.
East Granby, Connecticut
Dr. Lema
Stirs Controversy, Spurs Poem
I enjoy your
"Ventilations" and wish that they remain spontaneous
rather than mechanical.
Your review
of the massive snowfall coupled with the review of divergent views
responding to your articles about September 11 prompted this whimsy
I thought you might enjoy:
Snowflakes
Taking shape in circumstance
Snowflakes different arenšt we all
Lightly, brightly each to dance
Not so different we that fall
I listen
to the snowflakes
And I listen to you
I learn about a difference
And a oneness too
Peter J. Nelson,
M.D.
LaCrosse, Wisconsin
A Blizzard
of Concern Regarding Physician Supervision
I greatly
appreciated your February 2002 "Ventilations" article
on snow in Buffalo, New York, complete with pictures. As a graduate
of SUNY Buffalo's undergraduate and medical schools, I once thought
seriously about returning to Buffalo to practice.
However, I
am concerned about something that President-Elect James E. Cottrell,
M.D., alluded to in his article in the same NEWSLETTER
issue. He mentioned that the ASA Section on Education and Research
is developing an educational program for supervision of physician
extenders by nonanesthesiologists, apparently at the urging of
the American College of Surgeons. I was shocked when I read this.
Patient safety is best protected by supervision of nurse anesthetists
by anesthesiologists.
Is ASA supporting
supervision by surgeons? I realize this horse got out of the barn
years ago, but in today's climate of patient safety, we certainly
do not need to support and encourage this type of practice. Perhaps
you could address this topic in an upcoming NEWSLETTER.
Keep up the
good work! Buffalo is a great city!
Kevin L. Donovan,
M.D.
Jacksonville, Florida
Editor's
Note: ASA wishes to help surgeons medically oversee the
care provided by nurse anesthetists in areas where there are no
anesthesiologists to supervise them. This program is not intended
to replace anesthesiologists as it only presents a cursory understanding
of key practice issues to surgeons. By educating surgeons on important
anesthetic concerns, ASA is improving patient safety to those
underserved regions. In my experience, our surgical colleagues
are relinquishing more care to anesthesiologists where care overlaps
(intensive care unit and pain management). Thus it is unlikely
that a national trend to eliminate anesthesiologists from supervising
nurse anesthetists will fester among surgical specialties, especially
when both ASA and the American Association of Nurse Anesthetists
are anticipating workforce shortages. On the contrary, any and
all anesthesia personnel are likely to be welcomed at surgical
care sites.
–
M.J.L.
Plenty
of Room in PA/AA Pool
Wesley Frazier,
M.D., deserves to be recognized as one of the "fathers"
of the anesthesiologist assistant (AA) profession. I noted his
letter in the February 2002 ASA NEWSLETTER "Keep 'P'
Out of the 'AA' Pool" with interest. I must, however, disagree
with some of the points he makes. Dr. Frazier's claim that a physician
assistant (PA) with added clinical training in anesthesia could
"…work under the medical supervision of any physician…"
is absolutely not correct. A PA may only perform those duties
for which he or she is trained as long as it is within the scope
of practice of his or her supervising physician. A surgeon could
not supervise an anesthesia-trained PA. I worked for two years
as a surgical PA and have been a PA practicing anesthesia for
24 years. If I decided tomorrow to go work for a surgeon, I could
only do so as a surgical PA. The PA standard of practice mandates
this area-of-practice-specific relationship. This protects the
patient, the physician and the PA.
Dr. Frazier
also criticizes PAs practicing in specialty areas without accredited
specialty training or a specific national exam. The origin of
the PA profession was predicated in part on getting trained assistants
to physicians within two years. The supervising physician would
then integrate the PA into the practice as the physician wished.
To mandate formal training programs prior to a PA joining a practice
would severely limit the physician's ability to delegate (as is
permitted by law and custom). It also would limit the utility
of the PA profession as the training period would be doubled in
length.
Finally, regarding
third-party reimbursement for PA services, this is generally in
effect. I do not know specifics regarding reimbursement for PA-provided
anesthesia service, but I know that my supervising physicians
are reimbursed for my services.
I have the
greatest respect for Dr. Frazier and gratitude for what he has
done for the AA profession, but I do not share his concerns that
the use of appropriately trained PAs could do anything but enhance
the quality and quantity of anesthesia services provided in the
United States. There is room for us all.
Shepard B.
Stone, M.P.S., P.A.
Branford, Connecticut
Battling
for a Military Society
I read with
mental applause the article by Alvin R. Manalaysay, M.D., in March
2002 regarding the need for a military component society in ASA.
Having served nine years active duty in the United States Navy
and now having served nine years in the United States Air Force
Reserve, I am very familiar with the difficulties many military
and Veterans Administration (VA) anesthesiologists have in being
fully represented by, and within, ASA. When I served on the Committee
on Uniformed Services and Veterans' Affairs, I lobbied for such
a federal society and presented a draft resolution for consideration.
All my efforts fell on deaf ears at the time.
ASA membership
policies regarding military and federal practitioners are confusing
at best! All one has to do is review sections 1.3411, 1.3412,
1.3423, 1.3424, 3.111, 3.123, 3.125, 3.126 of the ASA Bylaws to
get a feel for the fuzzy and conflicting language regarding membership
for federal anesthesiologists, including those in the VA service.
It is time
that ASA clean up the requirements for federal physicians to have
a full representation within the Society, unobstructed by conflicting
membership regulations and red tape and without a dependence on
varying state component society bylaws language. A federal component
society for those federal anesthesiologists who are not licensed
in the state in which they practice would accomplish this very
nicely.
David A. Cross,
M.D.
Colonel, United States Air Force Reserve, Medical Corps
Temple, Texas
Create
Military Society Correctly
I applaud
Dr. Manalaysay's unflagging efforts to create a military component
society ("ASA Needs a Military Component Society," March
2002). He is to be congratulated on doing the "heavy lifting"
to make this concept a reality.
While I strongly
support the need for such a society, I advise that caution be
exercised when it comes to forming its objectives. In his article,
Dr. Manalaysay inferred that the society should take on such issues
as the expanding authority of nurses in military anesthesia and
pay inequities.
While I agree
that these are valid points of contention, a component society
of ASA is not the proper forum to debate these concerns. It is
true that many of us are frustrated by the frequent tilting with
the windmills of military bureaucracy; however, we do have the
responsibility to work within the system and make it respond to
both our and our patients' best interests. We will be doomed from
the start if we tackle problems that should be rightfully addressed
within the chains of command of the uniformed services. If we
gain the reputation of being a physicians' union, then any hope
for effectiveness will be gone.
John H. Chiles,
M.D.
Colonel, Medical Corps
Anesthesiology Consultant to the Surgeon General
of the Army
Washington, D.C.
Patients
and Anesthesiologists Trapped by Medicare – the Way Out
From the other
side of the country, I read with great interest the articles and
letters in the March ASA NEWSLETTER about Medicare fees,
the shortage of anesthesiologists and how this threatens Medicare
patients' access to anesthesia services. Here in Oregon, Medicare
fees are even lower than in Dr. Musumeci's Massachusetts. As nurse
anesthetists and anesthesiologists flee from our Medicare-rich
("Medicare-poor") practice to greener pastures, we are
frantically struggling to keep all of our busy operating rooms
filled with anesthesiologists or properly supervised nurse anesthetists.
There is mounting pressure to fill the gaps with unsupervised
nurse anesthetists. Stories abound of small- to medium-sized hospitals
whose entire anesthesia staff has fled. These hospitals then hire
whatever anesthesiologists or unsupervised nurse anesthetists
they can find – paying more for their services than they
can collect from the anesthesia billings alone. (It is interesting
to note that the more unified hospital associations are paid fairly
well by Medicare.) As a future Medicare victim myself, I am worried.
Perhaps you should be, too.
So far, this
is all just whining. If I were a Centers for Medicare & Medicaid
Services (CMS) bureaucrat, I would be saying (though not too loudly),
"Well it can't be too bad, they keep signing up for it!"
Did we forget that we voluntarily participate in Medicare?
Dr. Glazer's President's Update to us all last December
was horribly misleading.
We can choose
to be a participating provider, a nonparticipating provider, or
we can choose to have nothing to do with Medicare at all.
If we were to drop out of Medicare simply to be able charge these
folks whatever we wanted, we would rightfully be considered rapaciously
greedy. But choosing to stand by and do nothing while Medicare's
misguided policies slowly erode quality and access to our sickest
patients may be just as evil. We would be doing seniors (and ourselves)
a great service to find another way.
Here is a
way out of the Medicare trap. Are we strong enough to follow through
with it? We need to create another insurance choice for seniors
for anesthesia services. I know that I will want a better choice.
Medicare is clearly inadequate to assure continued access. For
a small premium, seniors could be assured of receiving prepaid
anesthesia services by an anesthesiologist. The plan could pay
for these services at, say, 50 to 75 percent of usual fees. Most
anesthesiologists would be thrilled to thereby receive two to
three times what Medicare pays.
There are
two hurdles here. First is the administrative job of setting up
this insurance plan. It would probably be best done locally or
state by state. If we are really ambitious, we can have needs-adjusted
premiums to help out those older folks who also are poor. Then
we would have to sign out of Medicare. Once out of Medicare, we
are free to provide services to these previously Medicare-trapped
patients under this (or any other) plan. We can then attract anesthesiologists
to come back to work in places that have been or are being abandoned.
As an extra incentive, once we have dropped out of Medicare, we
are no longer subject to CMS' expensive, bizarre and onerous billing
and practice rules and regulations. We will not have to worry
about going to jail for things like failing to have a surgeon's
order on record for every epidural that we performed in the past
10 years.
Rise to the
call, ASA. Do this for the trapped Medicare victims before I become
one. Do this for all of those Medicare-burdened hospitals around
the country who are struggling to keep their anesthesiology departments
full. And finally, do this for your anesthesiologists so they
can practice medicine, fairly reimbursed and free from Medicare's
burdens and threats.
Peter M. Lucas,
M.D.
North Bend, Oregon
Response
to 'Way Out' from Barry M. Glazer, M.D.
In response
to Dr. Lucas's letter, allow me first to acknowledge again that
ASA is well aware of the substantial staffing problems that currently
exist within the specialty. ASA is also well aware that inadequate
payment by Medicare, inadequate payer mix in general and care
for the indigent and underinsured all adversely impact the ability
of hospitals and anesthesiology departments to recruit adequate
staff to provide anesthesia services.
Although Dr.
Lucas' letter does not mention this, ASA is also very well aware
that the inadequacies in Medicare payment for anesthesia services
extend well beyond the recent 5.4-percent decrease in payment
to all physicians. During every opportunity that we can obtain,
we advocate vigorously for improvements in Medicare payment and
explain the access problems that inadequate payment creates, as
described by Dr. Lucas, especially for facilities with high Medicare
penetration.
I am sorry
that Dr. Lucas found my December letter to the members "horribly
misleading." It was written to provide information on how
to change one's status in Medicare from that of a participating
physician (the status that 90 percent of our members have) to
that of a nonparticipating physician in response to inquiries
from many members as to this process. It did not address how to
drop out of Medicare completely; we had not received inquiries
from members as to that process. Apparently, it was the failure
to mention this option that Dr. Lucas finds "horribly misleading."
Dropping out
of Medicare completely is not a realistic option for most anesthesiologists
or, for that matter, most physicians. Anesthesiology groups usually
have contracts requiring that they care for all patients who have
surgery in the facility, but even if they did not, legal obstacles
apply.
The American
Medical Association's explanation of "private contracting"
(the payment option advocated by Dr. Lucas) appears to be well-researched
and accurate. It states that:
Provisions
in the Balanced Budget Act of 1997 give physicians and their Medicare
patients the freedom to privately contract to provide health care
services outside the Medicare system. Private contracts must meet
specific requirements:
• The
physician must sign and file an affidavit agreeing to forgo receiving
any payment from Medicare for items or services provided to any
Medicare beneficiary for the following two-year period (either
directly, on a capitated basis or from an organization that received
Medicare reimbursement directly or on a capitated basis);
• Medicare
does not pay for the services provided or contracted for;
• The
contract must be in writing and must be signed by the beneficiary
before any item or service is provided;
• The
contract cannot be entered into at a time when the beneficiary
is facing an emergency or an urgent health situation.
In addition,
the contract must state unambiguously that by signing the private
contract, the beneficiary: gives up all Medicare payment for services
furnished by the "opt-out" physician; agrees not to
bill Medicare or ask the physician to bill Medicare; is liable
for all of the physician's charges without any Medicare balance
billing limits; acknowledges that Medigap or any other supplemental
insurance will not pay toward the services; and acknowledges that
he or she has the right to receive services from physicians for
whom Medicare coverage and payment would be available.
Although there
may be a handful of our members for whom such an option is realistic,
in practice, anesthesiologists who want nothing to do with Medicare
simply find practices with surgeons who do not accept Medicare
patients. Such practices are rare.
While I admire
thinking "out of the box," Dr. Lucas' idea to form an
insurance plan for anesthesia services only appears highly impractical.
Ignoring the tremendous costs and risks of setting up a single-specialty
insurance plan, patients do not wish to buy their insurance one
specialty at a time. Most Medicare patients would be angry that
anesthesiologists left Medicare and would not sign up for additional
insurance even at bargain prices when they perceive Medicare as
sufficient coverage for all their physician services. In the face
of these obstacles, such a plan would need to achieve a very high
penetration into the Medicare population to succeed – not
a likely occurrence.
A hospital-based
practice will almost inevitably include Medicare patients and
many (if not most) of them would not have entered into such an
insurance plan. The remaining Medicare patients would still require
anesthesia care, which the anesthesiologist would (hopefully)
feel obliged to provide but for which the "drop-out"
anesthesiologist could not bill. This care would become charitable
care – not the best solution to inadequate payment woes.
Medicare payment
for anesthesiology services most certainly needs fixing. But Congress
has not created a realistic "option" for most physicians,
let alone anesthesiologists, to completely leave the Medicare
system. Conventional advocacy, with documentation of the very
real access problems that are created by inadequate payment, is
our current and best strategy to correct this situation.
Barry M. Glazer,
M.D., ASA President
Indianapolis, Indiana
Problem
Solved
I had one
other thought on the current crisis with our Medicare conversion
factor. Why not have ASA make a firm request to the Centers for
Medicare & Medicaid Services that our annual Medicare fee update
be 50 percent tied to what our malpractice premiums did the previous
year and the other 50 percent tied to what our health insurance
premiums did last year? At least this concept, if enacted, might
make Congress look a little harder at legal reform as well as
take a closer look at all the money the big insurers are making.
Daniel M.
Podeschi, M.D.
Roanoke, Virginia
Medicine
and Medicare: David and Goliath for a New Age
History and
economics have overwhelmingly demonstrated that socialist-type
policies can lead to shortages in any industry. Government first
seizes the responsibility for providing goods or services below
market rates. Medicare is the perfect example. Of course, the
service quickly sells out of supply at below-market rates so shortages
develop. Students see the situation and choose other careers,
ensuring future shortages. Can government accept responsibility
for this? Of course not; the blame is laid everywhere else. In
fact, the crisis created gives government even more of a following
and an excuse to gain more control to "fix" the situation.
Delivering a cheaper product is one way to forestall the situation,
and soon we will see lowered requirements for international physicians
to gain licensure. A socialized industry (Medicare/Medicaid) cannot
compete with a free industry (private sector of medicine), but
government can handle that with a pseudo-market device: a government-sponsored
cartel called an "HMO." Recent proposals for extending
Medicare to those with an income up to 400 percent of the poverty
level, or down to age 55 with a co-pay or for a prescription drug
benefit are obvious attempts to close the ring around the small,
remaining private sector.
The entitled
groups empowering government include seniors on Medicare (forgive
me for slighting our deserving elderly, but it is a sad truth),
large employers, unions and, of course, most of our politicians
with the exception of a few lone conservative voices. Even many
politically naive physicians know the meaning of the term "the
third rail of American politics" when it comes to why our
politicians are uninterested in free markets in medicine.
There is a
solution, but it is draconian and possibly Pyrrhic. Physicians
must unanimously refuse Medicare and Medicaid except for emergency
care. They must agitate for medical savings accounts and against
employer-based insurance. They must support politicians who believe
in free markets, even in medicine. They must practice very wisely
and in a very cost-conscious fashion. They must be willing to
go out of practice for a time or even to go to jail. They must
be willing to treat the poor for less reimbursement. They must
have the self-respect to charge what they are worth. They must
somehow find allies perhaps in their younger patients, because
it is obvious that the groups listed above are truly vested in
our uncomplaining servitude. Remember, to willingly treat without
recompense is a godly act of love and charity. To treat without
recompense under government edict is a cowardly act of servility.
It occurs
to me that I said nothing about the growing use of isolated, specialized
and very likely unconstitutional laws against physicians to suppress
their economic independence: triple-damages for incorrect billing
(intentional or accidental) of Medicare/Medicaid; the use of imputed
dollar amounts based on a tiny statistical sampling of the accused
physician's billings; prohibitions against physicians owning business
assets related to their practices; grievous restrictions on practice
if you refuse to take Medicare; and of course, at age 65, you
are under Medicare whether you wish to be or not. Is this last
restriction not "age discrimination?" Ah, well... so
many polemics, so little time.
We know what
the future holds for our profession, for our medical schools and
for patients if we do not act. Even very bold hearts will quail
in facing such a huge opponent. Most likely, true action will
extend no further then these editorial pages, yet the Association
of American Physicians and Surgeons (AAPS) has made a start. Any
physician interested in joining the battle should consider membership.
Henry C. Walther,
M.D.
Granite Bay, California
Medicare
Free
You summarize
my feelings to a "T." I'm ready to take a stand. I was
at the recent American Society of Interventional Pain Physicians
meeting where Congressman Jerry Kleczka from Milwaukee said, "No
tort reform and no full reversal of the Medicare cutbacks."
Well, this is just another salvo. If we keep taking this, the
Medicare bully will just be back for more. It's time to explain
our position and the perceived future course carefully. It is
tempting to consider "just saying no" to Medicare until
things change. Yes, they could come after us with the assistant
attorney generals to investigate billing infractions or threaten
us with the Kennedy/Kassenbaum Fraud Act.
However, all
of medicine is at the breaking point, and we can no longer absorb
the losses.
Wesley K.
Greydanus, M.D.
Gig Harbor, Washington
We're Rich,
Relatively Speaking
The March
issue of the NEWSLETTER contains many references to the despair
of working long hours and poor monetary compensation on an hourly
basis. I too felt that way before retiring a few years ago.
I now have
the opportunity of spending most of my time associating with nonmedical
people (something that is not possible when working 3,500 hours/year
as an anesthesiologist). Many of these people who are your patients
do not believe you have much to complain about. They do not comprehend
the complexity of medicine and anesthesiology. They may not believe
that you really work that number of hours (no one does that anymore).
Many of your patients believe that you work no more hours than
they do. They don't understand what was involved in your years
of training and the many sacrifices you made in your social and
family life. They have no understanding that maybe you should
be compensated greater monetarily for holding peoples' lives in
your hands on a daily basis as compared to a businessman or top
manager whose acceptable goal is to make as much money as possible.
There is an
irony in your complaints when your patients observe you driving
those expensive cars and living in a house that they could never
afford and taking vacations of which they can only dream. They
are suffering when they seek your medical expertise, and many
of them suffer more when they receive your billing statement.
I cannot
foresee any change in this public attitude. Your patients believe
they have a right to the world's best medical care but have little
understanding of the demands placed on the medical community to
provide those standards. Your only hope to have a "normal"
life is for ASA members to set guidelines for reasonable work
hours. You must understand that this will result in lower incomes
because the public (government, insurance companies, HMOs) sees
no reason to increase compensation to a group who already receives
a much higher-than-average income.
Robert D.
Kuhl, M.D.
Salem, Oregon
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