ASA Submits Comments to CMS
Urging Revision in Teaching Rules
Michael Scott, J.D., Director
Governmental and Legal Affairs
SA
members attending the ASA Legislative Conference
in May were gratified to hear William D. Rogers,
M.D., head of the Centers for Medicare & Medicaid
Services (CMS) Physicians Regulatory Issues Task
Force, report that a sought-after change in the
agency’s teaching reimbursement rule was on
track for action this year. Then, about two months
later, another CMS representative — citing
the cost of the change — notified ASA that
the change would not be included in CMS’ proposed
physician payment rule for CY2005.
At issue was a request by ASA, first made to CMS
Administrator Thomas A. Scully last year, that the
reimbursement standard for anesthesiology teaching
be placed on a par with that applicable to teaching
in surgery and other high-risk specialties. In essence
the surgical rule is written in such a way as to
permit the surgeon to receive full reimbursement
for each of two overlapping cases, but the anesthesiology
rule expressly prohibits such a practice. When overlap
of two anesthesiology cases occurs, the medical
rules applicable to direction of nonphysician anesthesia
providers is applied, and reimbursement in each
overlapping case is halved.
Until 1994, Medicare carriers routinely permitted
teaching anesthesiologists to receive a full fee
for each of two concurrent cases involving residents.
Effective January 1 of that year, CMS changed the
reimbursement rule. Expressing concern with the
“disparity in payment allowances between two
concurrent procedures involving residents and other
[sic] nonphysician anesthetists,” CMS said
it would “uniformly apply medical direction
payment rules to concurrent procedures regardless
of whom the anesthesiologist is directing …”
A year later, the 1994 anesthesiology rule was incorporated
into new CMS generic teaching rules covering all
specialties. For surgeons and other high-risk specialists,
the requirement for full reimbursement was participation
in the key portion of the procedure and availability
throughout the procedure. At the same time, teaching
anesthesiologists were allowed full reimbursement
on satisfaction of these requirements but only for
a single case involving a single resident. In the
one instance, overlap was permitted; in the other,
it was expressly denied.
The impact of this CMS change on the financial viability
of anesthesiology teaching programs has been significant
— representing an estimated one-eighth the
amount by which institutions must subsidize academic
anesthesiology departments in order to keep them
afloat and to permit faculty positions to remain
competitive with practice opportunities in the private
marketplace. With these departments already struggling
to meet demand (there are 300 fewer available residency
positions per year than the estimated 1,600 positions
annually required to meet growth in demand in the
next several years), the CMS teaching rule penalty
has become a significant factor in departmental
health.
When ASA representatives met with CMS Administrator
Scully last year, he expressed concern about the
situation and subsequently caused, effective last
January 1, an alternative reimbursement methodology
to be made available in the case of concurrent teaching
of two anesthesiology residents. This methodology
was originally designed, however, to cover the teaching
of student nurse anesthetists, and anesthesiology
program directors uniformly expressed their dissatisfaction
with the new alternative. Thus, beginning early
in 2004, ASA renewed its efforts with CMS to attempt
to achieve parity with teaching surgeons and were
under the impression that substantial progress was
being made until receipt of CMS’ letter of
denial in mid-summer.
Recognizing the critical importance to the specialty
that an adequate number of new physicians be trained
each year, ASA officers reacted with some vigor
to CMS’ advice of denial. They promptly authorized
expansion of ASA’s “outside legislative
team” to include individuals closely familiar
with CMS reimbursement policy decisions and authorized
Alexander A. Hannenberg, M.D., Vice-President for
Professional Affairs, to initiate renewed discussions
with the responsible CMS officials.
These discussions occurred in mid-August, and by
Labor Day, ASA had submitted an extensively documented
letter spelling out the unfairness of the current
CMS discrimination against anesthesiology teaching.
The letter points out that at no time in applying
the medical direction rule to all concurrent cases
did CMS ever consider differences between the teaching
of resident physicians and the supervision of technique-trained
nonphysician providers. ASA’s letter also
emphasizes the similarity between surgery and anesthesia
in the context of defining the key portions of the
procedure.
It is not currently clear what action, if any, CMS
will take in response to ASA’s letter. Members
attending the House of Delegates meeting in Las
Vegas, Nevada, this October will be updated at that
time by ASA officers, and further developments will
be updated in this column as they occur.
CMS Improves
GME Funding
n its FY2005 final rule relating to the Medicare Hospital
Inpatient Prospective Payment System issued August
11, CMS announced, as it proposed a few months ago,
that in the case of medical students simultaneously
matching into anesthesiology or a clinical base year,
it will weight the student’s fourth residency
year as a full 1.0 full-time equivalent (FTE) for
direct graduate medical education support purposes,
even when the clinical base year is devoted to a specialty
requiring only three years of training. In other words,
the duration of the residency for simultaneously matching
students will be measured by the student’s specialty
in his or her second year of training. Heretofore,
CMS instructions to intermediaries required that when
the duration of residency training in the clinical
base year was three years, as in the case of internal
medicine, only 0.5 FTEs would be recognized for the
last year of anesthesiology training. ASA, along with
the Association of American Medical Colleges, supported
the change when it was first proposed.
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