In 2001 the ASA House of Delegates established the Committee on Rural Access to Anesthesia Care. The committee’s first course of action was to review documents suggested by our predecessor, the 1994 Task Force on Anesthesia in Underserved America, established by ASA Past President Wilson C. Wilhite, Jr., M.D. Committee members Joseph Johnson, M.D., Paul D. Martin, M.D., and M.O. “Neill” Lee, M.D., also served on that task force. The following documents were helpful in establishing a common language: “Rural Hospitals: Accomplishments and Present Challenges”; The Quality of Medical Care in the United States: A Report on the Medicare Program; and the Tarrance Group survey commissioned by ASA called “Surgical Care: A Survey of Rural Hospitals.”

We focused on four main areas during our first year. We named subcommittees to address ASA rural membership identification, coordination with academic programs, ASA Annual Meeting program development and economic disparity of rural versus urban practices. Since many rural anesthesiologists have difficulty finding coverage to leave for face-to-face meetings, the committee has communicated primarily via an e-mail listserve for our first three years. We had no budget the first year, but ASA helped us with research and clerical support to identify an initial list of rural anesthesiologists. The next year, we had a budget of $15,000 but spent less than $1,000, proving that our fledgling committee can be a model of sorts for working with much less expenditure.

ASA Rural Membership Identification
With the assistance of ASA and ZIP code analysis, our committee identified more than 600 ASA members living in rural areas. We sent a mailing inviting these anesthesiologists to join us for a meeting at the ASA 2002 Annual Meeting in Orlando, Florida. In addition e-mail invitations were sent to academic anesthesiologists involved in the Association of Anesthesiology Program Directors and the Society of Academic Anesthesiology Chairs and component society presidents and secretaries asking them to identify and encourage anesthesiologists with interests in rural anesthesiology to attend. We have been listed on the ASA Web page for open meetings at the ASA Annual Meeting the last two years.

ASA Annual Meeting Program Development
We gave a PowerPoint presentation and informal panel discussion at the 2002 Annual Meeting. John C. Chatelain, M.D., Wallace H. Good, Jr., M.D., Roger W. Litwiller, M.D., Paul D. Martin, M.D., and I provided background, demographic statistics and tips for working with hospital administrators and arranging for work coverage. Sheila J. Ellis, M.D., coordinated with academic anesthesiology. This program introduced and discussed some of the challenges of rural anesthesiology practices, and some solutions were discussed. Cooperation and communication with academic and rural anesthesiologists were encouraged. The economics of rural anesthesiology was a hot topic. Vacation and continuing medical education (CME) leave times can be difficult to arrange, and many solutions were proposed. Comments, suggestions and questions from the audience were encouraged. A similar, more informal format was utilized at the ASA 2003 Annual Meeting in San Francisco, California. Eric W. Mason, M.D., attended in place of Dr. Litwiller. We plan to have a formal panel in the future.

Obstetrical Services
Discussion continues on the rural listserve about providing better labor analgesia coverage and vaginal birth after cesarean section availability while still servicing the operating room with limited staff. Some hospitals are demanding labor epidurals instead of intrathecals even in areas with fewer than 700 deliveries per year. This labor epidural coverage requires more anesthesiologists/nurse anesthetists to be available to provide coverage for the same number of patients. Many rural hospitals and anesthesiologists have agreed to risk-sharing arrangements to help compensate anesthesia and improve retention. Some states have significantly increased their Medicaid payments for obstetrical anesthesia after vigorous lobbying efforts.

Preoperative Screening
Rural anesthesiology provides unique challenges in preoperative screening. Some patients may travel 200-300 miles or more one way for their surgery. Working up these patients prior to the day of surgery is often difficult. Finding laboratory reports and medical records from outlying physician offices or mid-level clinics can be time-consuming. Many different solutions exist and were shared on the listserve. High-quality care is always the goal, but many factors make it very time-consuming and occasionally unpopular to accomplish.

Medical Student and/or Rural Resident Rotation
Many ideas have been discussed to increase awareness in medical students of the opportunities and rewards of anesthesiology in rural areas. For example, in order to recruit residents to rural areas in the first place, a scholarship fund might be established at the senior medical school or internship level. Many rural areas of the country have informal/formal relationships with local medical schools. Some residency programs have rotations in community operating rooms. Many obstacles exist in trying to meet residency regulations, professional liability coverage, economics, shortages of residents and even resistance among local rural surgeons or hospital administrators.

Economic Disparity
We have worked with Congress to increase Medicare reimbursement directly to rural physicians and hospitals. The 2003 House of Delegates passed a resolution to support legislation for parity in Medicare payments. It was a major accomplishment when the 2003 Congress supported the concept of “equal pay for equal work.” The geographical practice cost index was raised to set a floor at one. This increased 2004 Medicare conversion factor payments by about 8 percent to 9 percent for rural providers because of legislation in the Medicare Modernization Bill. Some small rural hospitals are reimbursed on a “cost basis” for nurse anesthesia services but not for anesthesiologists’ services. The final result is still lower reimbursement on average in a rural area compared to an urban area. This economic disparity impacts recruitment, retention, call coverage, vacation coverage and the ability to obtain CME.

The committee encourages any ASA member interested in joining our listserve to subscribe to <rural@listserv.ASAhq.org>. When sending a message, please write “Subscribe” in the subject line of the e-mail. We encourage open discussion — the best ideas have come from these open Internet comments. Our goal is to improve access to high quality rural anesthesia care.

Committee members are Dr. Schweitzer, Chair, Dr. Chatelain, Philip S. Henkel, M.D., Dr. Lee, Dr. Martin, H. Douglas Roberts, M.D., and Joseph C. Seelig, M.D.

Mike P. Schweitzer, M.D., is a staff anesthesiologist, Medical Director of O.R., member of the Executive Committee at St. Vincent Healthcare and a board member of InterWest Health and Rocky Mountain Health Network, St. Vincent Healthcare, Billings, Montana.