A Resident’s Perspective on CMS’ Teaching Rule

cademic anesthesiologists running two resident-staffed operating rooms (O.R.s) with Medicare patients are compensated for only one room. This has been the case since 1995, when the Centers for Medicare & Medicaid Services (CMS) enacted its infamous “teaching rule” reimbursement policy for anesthesiology. Outrageously, an academic surgeon similarly running two resident-staffed O.R.s with Medicare patients receives full reimbursement for both cases, as does an internist or pediatrician overseeing multiple resident clinic rooms, or an academic emergency room physician overseeing concurrent procedures/workups performed by residents on Medicare patients.

Despite numerous assurances that the rule would be changed, CMS did not modify its unfair teaching rule policy in the proposed 2006 Medicare fee schedule changes, which were released on August 1. Academic anesthesiologists remain the only high-risk specialist prohibited from performing overlapping cases and receiving a full fee for each.

Over the past decade, this unfair compensation scheme has demolished academic anesthesiology departments across the United States, both from a fiscal and workforce perspective. Resident education has suffered as our attendings’ energies are diverted to keeping departmental finances in the black. O.R.-to-attending ratios have increased (with nurse anesthetist staffing) in order to balance the books, leaving less time for hands-on teaching. The teaching rule’s financial strain on departmental morale is obvious — and lessens the attraction of entering academic anesthesiology for the graduating resident.

In ASA’s 2004 comments to CMS regarding the teaching rule, former ASA President Roger W. Litwiller, M.D., noted the failing health of academic anesthesiology departments. According to a survey of departments, 78 percent had open faculty positions (average 3.7 open positions), and 25 percent of departments closed an anesthetitizing location due to lack of faculty. ASA estimates that the teaching rule costs roughly $463,000 per teaching program annually and notes that hospital institutions had to take up Medicare’s slack by increasing institutional support per full-time equivalent by 75 percent from 2000-02 and another 43 percent in 2003. (ASA’s 2004 teaching rule comments can be viewed at <www.ASAhq.org/Washington/ASACommentsonTeachingRuleSep04.pdf>.

The impact on anesthesiology residents is obvious. A decreased number of academic anesthesiologists also will decrease the number of mentors for research. With staff being pulled into O.R.s to cover cases at the expense of academic time, department budgets drying up and morale low, academic endeavors suffer. If we do not continue to encourage and foster future research and researchers, then we will relinquish our role as leaders in the field of anesthesiology. With issues such as scope of practice and intraoperative awareness looming, we must remain in the forefront.

Not only will the availability of academic anesthesiologists to residents continue to dwindle under the current teaching rule, but so too will the opportunities of residents to work with the elderly. Faced with a reduction in payment if they let a resident participate in an additional Medicare case, many programs are forced to exclude residents in favor of staff running the rooms with nonphysician anesthesia providers. The number of opportunities a resident gets to provide anesthesia to elderly patients is being diminished in some institutions by the teaching rule. Less experience handling the multiple comorbidities that come with an increasingly aging population will result in less well-trained anesthesiologists and potentially poorer patient outcomes.

Additionally our best and brightest colleagues have historically been heavily recruited to stay on as faculty at academic institutions. With the reimbursement restraints imposed by CMS’ teaching rule, however, attendings are essentially functioning as private anesthesiologists at 50 percent of the compensation: running three or four operating rooms, no academic days to organize resident teaching/research and minimal time for hands-on resident teaching in the operating room. Where, then, is the attraction in academic anesthesiology?

The current Medicare teaching rule is unfair to academic anesthesiologists and dangerous to the future of anesthesiology and must be fixed. The real threat of not fixing it lies in a future generation of anesthesiologists who are not as well prepared as they could or should be.

A decision not to fix the teaching rule will seriously hurt the quality of resident education and the safety of the patients they will care for in the future. In the face of an increase in the elderly population, the very population Medicare serves, such a decision seems penny-wise and pound-foolish.

ASA asks that all members write letters to their Members of Congress about the teaching rule. You can contact Capitol Hill via the Web at <www.ASAhq.org/news/cmsproposal082405.htm>.

Jerome Adams, M.D., M.P.H., is a CA-3 resident at Indiana University Department of Anesthesiology, Indianapolis, Indiana. He is the ASA Resident Component’s Alternate Delegate to the American Medical Association Section Council for Anesthesiology.