Douglas R. Bacon, M.D., Editor

Me vs. We

s I write these words, the Advent season is upon us. It is a time of great anticipation in my house, for Christmas is coming. While as Christians this is an important religious holiday, there is a tremendous commercial aspect to the celebration. My youngest son, who just turned seven, seems caught up in the trappings of the holiday.

With help from my wife, Tommy had the Christmas tree up two days after Thanksgiving. It is a time of the season when we often create lists of gifts we should like to get, and Madison Avenue does its best to make us believe we really need these things. Our attention to those less fortunate is also heightened at this time. Daily opportunities arrive in the mailbox to contribute to those less well-off than ourselves. It is the season of the year where “me” and my interests run strong with “we” and the interests of our families and humankind in general.

Resolution of “me” versus “we” is one of life’s hardest lessons to learn. When should my interests be put ahead of a group? As anesthesiologists we are faced with this dilemma over one of the most divisive issues possible within the specialty, that of reimbursement. At the ASA 2004 Annual Meeting, reports from the Task Force to Study Payment Methodology were given a separate reference committee in which to be heard. Three reports consumed an entire afternoon as this special reference committee began an hour before the other four reference committees and took testimony from members long after the other four committees were finished.

The contentious issue was time. Unlike every other specialty in medicine, anesthesiology is compensated by time. Originally this was to recompense anesthesiologists for slow surgeons — thus an anesthesiologist working with a surgeon who could perform four cholecystectomies in a morning made roughly the same amount of money as the anesthesiologist who worked with a surgeon who could only perform two such procedures. Currently both Medicare and third-party insurers are looking to change this practice. The carrot held out to the anesthesiology community is that there will be an increase in reimbursement for each unit once time has been eliminated. At the moment that I write these words, there is no written agreement to that effect. There is a “deal” that is continuing to be negotiated with the federal government.

There should be no rush to eliminate time from the reimbursement equation, although I believe it will be lost inevitably. The challenge before the anesthesiology community is to ensure that the best possible deal is struck with the Medicare powers that be before radically changing our compensation calculation. As recently evidenced by the government’s unwillingness to correct payment for academic anesthesiologists, there should be a healthy skepticism over any purported deal until we actually see the wording and can comment upon the language of the agreement. It was strongly suggested to ASA that full reimbursement for both anesthetics, when an anesthesiologist was covering two residents, would be resolved in the rules when promulgated this year. Yet when the document came forth for comment, this change was missing despite all the assurances that it would be present. This lack of income is crippling many of the major academic centers as they struggle to hold on financially. If academic centers start to fold, anesthesiology as a physician specialty is one generation, less than 30 years, from demise. The impact of this negotiation is so great that it cannot be simply left to a handshake.

Likewise, when the new order of compensation calculation is agreed upon, it cannot be done in the old gentlemanly way — by a handshake. No matter how good your friendship is with or how much influence the group may have within the federal bureaucracy, there are those willing to torpedo the deal. Even a written document is difficult in that oftentimes the written word can be interpreted in different ways. There would be no better outcome for the federal government than to somehow turn anesthesiologists against other specialists within medicine in a “fight” over the almighty dollar. In a zero-sum game where the total number of dollars available for Medicare is capped, from where will the additional dollars for anesthesiology come? Will our cardiac surgical colleagues voluntarily give up a percentage of their income to add to the anesthesiologists, or will they fight both the government and the anesthesiology community? It is a situation that “we” must avoid.

As you read these words, the New Year is upon us. It is a time of reflection and resolution to improve ourselves. It is, in many senses, a “me” time yet “we” are hopeful for many positive consequences. While we celebrate the past 100 years of greatness and look to our future, we need to look as the original founders of the Long Island Society did a century before. What are the best interests of our patients? In terms of reimbursement, that is a delicate matter; but without a living wage, anesthesiology will cease to exist as a physician specialty in a few short years. With it will perish the longstanding hard-science investigations that have made the passage through the anesthetic state so safe. We must, in my opinion, give up time in our formula for compensation. The question is not if, but when. And for the betterment of the specialty, “we” need to cut the best deal possible — one that is written within the law of the land.

— D.R.B.

return to top