June 2002
Volume 66 |
Number 6
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| Letters
To The Editor |
Is the ASA Leadership Listening?
In the March NEWSLETTER, I was pleased to finally see
a clear message from several anesthesiologists (Ross J. Musumeci,
M.D., Daniel M. Podeschi, M.D., Jerry Stonemetz, M.D., and an
anonymous letter writer) about the need for significant increases
in Medicare/Medicaid reimbursement for anesthesiology services.
Following is a summary of many comments elicited from the March
NEWSLETTER:
Statements on current payment rates:
- Flat out wrong, if not ludicrous
- Demoralizing
- Reimbursement is poor at best
- Rates are already so egregiously low
- Problems with Medicare now go well beyond the issue of fairness
- Dismayed, disappointed and angry
- Disgracefully low Medicare rates
- Blatant unfairness of the Medicare Fee Schedule
- More than a 100-percent increase will be needed to make
Medicare rates even close to competitive
Statements on proposed solutions:
- Ask ASA leaders to strongly denounce new Medicare rate for
anesthesia
- ASA leadership [should] take a more aggressive stance in
its challenge to the Medicare Fee Schedule
- Only when we become militant will anyone listen to us
- Contribute to ASA Political Action Committee
So again, I ask, is the ASA leadership listening? We should have
a strategy that will result in a doubling in the Medicare rate
for anesthesiology by next year. Using our resources to fight
an across-the-board cut in Medicare rates is not the best way
to achieve a fair fee schedule for anesthesiologists. All anesthesiologists
should encourage state and national societies to make this a top
priority today.
Craig A. Westwood, M.D.
Harrisonburg, Virginia
Response from Dr. Glazer
ASA leadership agrees with every one of the "statements
on the current payment rates" from Medicare. The ASA Legislative
Conference on April 29 - May 1, which will be historical by the
time this is printed, will have had Medicare payment problems
as our primary issue on which we lobby.
We constantly consult with our expert staff and lobbyists as
to appropriate strategies to address this problem. At this time,
militancy will not accomplish anything positive. Unfortunately,
as recently explained in my President's Update from April
3, 2002, the current budgetary restraints and congressional and
administration priorities make a long-term, fully adequate correction
to our Medicare payment levels unlikely at this time, regardless
of our strategies. There is reason to believe, however, that the
107th Congress will ameliorate the projected cuts, at least in
the short term, before it adjourns later this year.
We are fully committed to vigorous advocacy to assure that Congress
understands this problem, and we educate our legislators at every
opportunity on the unacceptable Medicare payment level for anesthesiology
services. Access problems are real and progressive, and this manifestation
of the payment inadequacies may be our best argument for a repair
of the system.
Barry M. Glazer, M.D.
ASA President
Straightening Out RVU Formulas
Editor's Note: Recent letters about Medicare's serious
undervaluation of anesthesia services have reopened discussion
about an article we published two years ago (Jablonski VN, Marshall,
WK. A methodology for the calculation of anesthesia relative value
units. ASA Newsl. 2000; 64(4):19-23). The issues and concerns
raised by the article, however, are no less important now than
they were before, so we decided to revisit the discussion and
add an update. – M.J.L.
Virginia N. Jablonski, M.S.A., and Wayne K. Marshall, M.D., are
to be commended for addressing the very real and important issue
of productivity comparisons within a multispecialty group. Most
multispecialty groups do not understand Relative Value Unit (RVU)
calculations versus units of work for anesthesia. However, we
are concerned that the publication and our membership's ensuing
use of this methodology will do more harm than good. The article's
assumption was that imputed RVU work values based on reimbursement
[as developed by the Center for Medicare & Medicaid Services (CMS)]
was an accurate reflection of the work of anesthesiologists. Our
own society regularly contends that the work values and reimbursement
assigned by CMS to anesthesia are grossly unfair.
A subsequent article by Norman A. Cohen, M.D., in the June 2000
ASA NEWSLETTER ("Between the RUC and a Hard Place")
makes note of the efforts we are expending at the national level
to undo CMS' erroneous assessment of our work. If we compare RVUs
using Jablonski and Marshall's methodology, we will be understating
our work effort by at least 40 percent. ASA has published a workbook1
on how we can equate what we do to other specialties, and two
recent publications2,3 have
addressed this issue as well. The conclusion? If we were paid
for what we do like other specialists, our reimbursement should
be 1.8- to 2.2-fold higher than it is. Therefore, a "work
value correction factor" of 2 should be applied as part of
the formula in the numerator. The result: a doubling of
RVUs by anesthesiologists. This would then truly reflect the work
we do (rather than the amount we are paid by CMS). I suggest that
the new formula for conversion of anesthesia units to RVUs be:
{(base + time units) * anes conversion factor/surgical conversion
factor} * specialty share weight * WORK VALUE CORRECTION FACTOR
= work RVUs for anesthesia.
The formula above is only appropriate for physician care where
all time and interpretative work and intensity is done by the
physician. With supervision of multiple providers, I suggest subtracting
the dependent provider component = one-half the time units (without
the doubling factor). Dependent providers usually provide care
during the less intense parts of care and are joined by the physician
in charge of the case during all critical parts of the procedure.
This is reflected in the personal participation requirements that
CMS has for medical supervision of nurse anesthetists. ASA did
not address care team issues when it looked at the CMS underpayments.1
A factor of (n/n-1, where n= average concurrency ratio) is used
to denote the fraction of time when an anesthesiologist is certainly
not present. Given practice norms outside of an exclusive cardiac
practice, I would suggest that n be greater than or equal to 2,
as supervising anesthesiologists do not usually spend more than
one-half of their time in the room, even if the supervision ratio
falls below 2. The formula for care team practice would be:
[(total base + total time units) * anesthesia conversion factor
/ surgical conversion factor * specialty share weight * WORK VALUE
CORRECTION FACTOR] – [(n-1/n) * (dependent care provider
time units) * anesthesia conversion factor/surgical conversion
factor * specialty share weight] = work RVUs for anesthesiologists
– work RVUs for nurse anesthetists, anesthesiologist assistants
or residents = total physician work to provide anesthesia.
To get total RVUs, one must remember to add in traditionally
valued RVU procedures such as preoperative consultations, pain
management, pulmonary artery catheterizations, etc.
An example of how an anesthesiologist routinely supervising two
residents each doing an incisional hernia repair for two hours
might value his or her RVUs:
WORK VALUE CORRECTION FACTOR = 1.8
N=2
Specialty share weight = .782
Anesthesia conversion factor = 17.76
Surgical conversion factor = 40.96
Base units/case = 6
Times units/case = 8
{[(6+6)*1.8] + [(1.8-1/2)* (8+8)]}*17.76/40.96*.782 = RVUs = 14.4
David A. Lubarsky, M.D.
Miami, Florida
Joseph G. Reves, M.D.
Charleston, South Carolina
References:
1. Hannenberg AA. Medicare & anesthesia reimbursement
methods: The Medicare fee schedule is the wrong benchmark for
commercial anesthesia payments. In: Practice Management: Anatomy
of the Bargain: Sword, Shield or Shackle? Syllabus of the American
Society of Anesthesiologists 1999 Conference on Practice Management,
Lecture 16:1-23.
2. Johnstone RE, Hosaflook C. Financial impact
if payers use Medicare rates. Anesthesiology. 2000; 93:852-857.
3. Lubarsky DA, Reves JG. Using Medicare multiples
results in disproportionate reimbursement for anesthesiologists
compared to other physicians. J Clin Anesth. 2000; 12:238-241.
Response from Karin Bierstein
Dr. Lubarsky and Dr. Reves are correct that Medicare undervalues
anesthesia services. The current national average Medicare conversion
factor, $16.60, is just a little more than one-third of the 2001
commercial average, $45-$47. His "work value correction factor"
is indeed necessary to place anesthesia on the same scale as other
specialties, and it is probably closer to 2.7 than to the 1.8
or 2.2 that the Lubarsky/Reves data suggested. Alexander A. Hannenberg,
M.D., now chair of the Committee on Economics, made a similar
point in his letter to the editor ("Not Everything Is Relative
When Calculating RVUs") in the June 2000 issue of the NEWSLETTER.
The proposed method for measuring anesthesiologists' work when
it involves medical direction of residents, nurse anesthetists
or anesthesiologist assistants, is a valuable contribution. The
portion of the formula reflecting the reduction for concurrent
cases is not consistent throughout the Lubarsky/Reves letter,
probably because of a typo. It is introduced in the second paragraph
as "(n/n-1," and it appears following "The formula
for care team practice would be:" as "(n-1/n)."
Given that N=2 in his two-resident example and that the resulting
value is 1/2, the formula should instead read "(n-1)/n."
Dr. Lubarsky and Dr. Reves are also quite right to point out
that in order to account for all anesthesiology work in a day
or in a single case, one must include the work RVUs for services
such as visits and the placement of lines and catheters and not
simply reflect imputed RVUs for the anesthesia services. Fortunately
the RVUs for the other services can be taken directly from the
Medicare Fee Schedule. Readers should note that if they are comparing
RVUs across specialties, it is important to know whether everyone
is using just the work RVUs, or total RVUs (work+practice expense+professional
liability expense). All the specialties need to be speaking the
same language.
Hard Days' Nights for Naught?
It is always with great anticipation that I read your "Ventilations"
section in the ASA NEWSLETTER every month, Dr. Lema. You
speak your mind whether it's politically correct or not. I wish
more physicians would speak based on what's right and not on who's
right or what is the best political avenue to drive through. I
especially appreciate all the material you've written regarding
anesthesiologists' well being not only for our own personal good
but also how it relates to patient care. Optimal patient care
is only as good as how we care for ourselves.
Your last commentary in the March 2002 issue of the NEWSLETTER
"It's Been a Hard Day's Night," was so well written
but especially right on target. The unfortunate thing is those
who read it are those who agree with you; those who don't probably
won't. If they can't hear it, they won't read it. In my very simplistic
view, I've come to the conclusion that we physicians have, to
a certain degree, contributed to the financial, moral and managerial
mess that we're in. Rather than taking a stand – a strong
stand – once we saw the writing on the wall, we sort of went
along with it and tried to get as much as we could out of it by
"beating the system." But beating the system meant,
as you wrote so well, hurting ourselves by working outrageous
hours to try to squeeze as much as we could from it. That in turn
leaves us fatigued, more vulnerable to stress and not as sharp
as we should be. This exists not only in the health care industry
but in an acute care specialty. We've shot ourselves in the foot
by now helping to create an environment that is not necessarily
attractive for senior medical students. How shortsighted can we
be? Again, the writing is not only on the wall, it's on the ceiling
and the floor. We have to stand up and say, enough, already! If
we were to primarily focus on quality patient care and minimizing
risk, the situation wouldn't be as bad as it is.
I can only hope that more and more physicians get on your bandwagon
and realize that the way we have dealt with what has affected
us has not been in our best interest, nor for the interest of
our patients.
A Pediatric Anesthesiologist
(Name withheld on request)
It's Been a Hard Day's Night, but Not for CEOs
I heartily agree with your article, "It's Been a Hard Day's
Night," that appeared in the March 2002 "Ventilations."
One small detail: It is unlikely that the CEO would approach you
at 8:30 in the evening to extract more work. A telephone call
from his or her weekend home would be the more realistic scenario.
Keep up the good work.
Samuel Tirer, M.D.
Philadelphia, Pennsylvania
Dental Error?
I empathize with the concerns of Malcolm T. Klein, M.D., for
his daughter's safety in the dentist's office ("Safety Wisdom,"
March 2002). He made nine references to the use of Novocaine by
his daughter's dentist. I doubt whether his dentist was using
that agent. He was probably using Lidocaine. Perhaps Dr. Klein
was using Novocaine as many lay people do, as a euphemism for
"local" anesthesia. In any case, it was dentists who
were among those who introduced Lidocaine about 50 years ago.
They quickly appreciated its advantages over Procaine: rapid onset,
better spreading factor and longer duration.
Martin W. Livingston, M.D.
Mamaroneck, New York
Catching Errors Can Be Like Pulling Teeth
Dr. Livingston's observation is correct. My article was initially
written for lay publication. Accordingly, I used the familiar
term "Novocaine" as a genericidal reference to local
anesthetics used in the dental office. During the rewrite for
submission to the ASA NEWSLETTER, the term unfortunately
escaped the editorial process. This oversight underscores the
fact that even an article on error is not immune from error.
Malcolm T. Klein, M.D.
Tampa, Florida
Pelican Brief Poem
Reference is made to "pelican anesthesia" in the March
2002 NEWSLETTER.
There are good people in this world, and Dale Shields is, of
course, one of them. He, on retirement, could have devoted himself
to golf or some other form of entertainment, but he chose to rescue
injured pelicans.
Those of us who have seen, close up, these somewhat ungainly
birds dive head-first from a frightening height to catch fish
do not soon forget it.
I would like to, perhaps, bring a smile to those of us who are
and were engaged in the sometimes grim business of anesthesiology
by quoting a limerick by Dixon Lanier Merritt.
"A wonderful bird is the pelican
His mouth holds more than his belican €He takes in his beak
Enough food for a week
But I'm damned
If I see how the helican."
Benson Bodell, M.D.
Houston, Texas
Be Wary of FDA Droperidol Warning
The Food and Drug Administration (FDA) has recently issued a
warning concerning droperidol. [April 2002 NEWSLETTER].
This warning also was mentioned in the Winter 2001-02 Anesthesia
Patient Safety Foundation Newsletter. The FDA warning indicated
that there was a significant risk of droperidol inducing serious
arrhythmias, even when used in "low" (0.625-1.25 mg)
antiemetic doses. The severity of the warning effectively threatens
the routine use of the most cost-effective antiemetic administered
to millions of patients over several decades. I was skeptical
that evidence existed justifying the FDA's warning. I also felt
that, to a certain degree, "strong-arm" tactics were
being employed. Therefore, under the freedom of information act,
I acquired the FDA's printout of the adverse reports leading them
to their conclusions. Interestingly, I needed to inquire three
times and wait more than two months for the FDA to forward the
requested information to me.
The facts of the adverse droperidol reports were more than interesting.
They can be tabulated in many ways. Briefly, however, there were
273 adverse reports, although several of the cases contained in
the report were obvious duplicates or even triplicates. The cases
were reported over a four-year period from late 1997 to late 2001.
I tried to separate from these 279 cases those that reported arrhythmias
as an adverse outcome, especially those identified as either prolonged
QT interval or Torsades. I was also interested in what the range
of doses of droperidol was in those particular cases and whether
or not other drugs were concomitantly administered.
Eight cases involving 0.625 mg were reported, but two of these
were duplicated, resulting in only six such cases in total. Three
patients receiving 0.625 mg experienced a tachycardia (presumably
sinus), two experienced ventricular tachycardia and one experienced
Torsades. Of the cases containing a report of prolonged QT, doses
of droperidol were 50 mg, 250 mg (orally), and 0.25 mg/kg. Of
the 13 cases reporting Torsades, droperidol doses were 0.625 mg
(n=1), 2.5 mg (n=2), 3.75 mg (n=1), 25 mg (n=2), 200 mg (n=1),
240 ml (n=3) and an unknown amount in another three cases. Additional
medications were administered in most but not all of the cases.
Many other adverse outcomes also were reported. Frequently, high
doses of droperidol and other drugs were involved, and/or cases
were complicated by suicide, alcohol intoxication, etc. For example,
of the 79 cases where an arrhythmia was reported, nine involved
a droperidol dose of 10 mg or more, and 33 involved a dose of
20 mg or more.
I fail to see how the data contained in the summary of the adverse
reports could be interpreted to mandate the severe warning issued
by the FDA, in particular in its implication for prophylaxis and
treatment of perioperative nausea and vomiting. In addition, the
majority of the serious adverse reports involve outrageous doses
of droperidol, frequently in patients receiving other psychotropic
medication. Finally, the source of many of the adverse case reports
was often identified as "foreign."
I, like many other anesthesiologists, have administered droperidol
to hundreds of patients in the dose of 0.25 to 1 ml, for many
years. The only hemodynamic consequence I ever see is a predictable
(and often intended) decrease in blood pressure of 20-30 mm Hg
that lasts for five to 10 minutes. If one separates out this dose
from the adverse report summary, there are three cases where a
dose of droperidol of 0.625 to 2.5 mg resulted in Torsades. At
roughly one case per year (three cases over four years) and in
light of the likely enormous denominator considering the widespread
use of droperidol, this can hardly be a serious indictment.
The literature supports the use of droperidol as a first-line
antiemetic for postoperative nausea and vomiting (PONV). In light
of the FDA's warning, many hospitals must now feel obliged to
remove droperidol as the first-line perioperative antiemetic.
Are the alternatives safer? Ondansetron and other similar drugs,
if routinely substituted for PONV prophylaxis and treatment, will
certainly significantly increase related costs. This is not to
mention that quite a few of the patients in the same adverse drug
reports also received ondansetron.
The FDA should reconsider how it comes to making its rather dramatic
but all too often unscientific warnings. They should also ponder
the consequences of their actions and the alternatives that clinicians
will be forced to use. I certainly hope the FDA is not being led
by its nose by the pharmaceutical industry, which certainly does
not stand to make much money from any of the "older"
drugs that we use. Witness the repeated shortages of commonly
used, excellent and necessary drugs such as fentanyl and naloxone.
Peter L. Bailey, M.D.
Rochester, New York
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