The Medicare Teaching
Rule —The Battle Has Been Joined
Ronald Szabat, J.D., LL.M., Director
Governmental Affairs and General Counsel
n a dramatic response to ASA’s late-summer
“call to action,” hundreds of academic
anesthesiology departments, program directors, resident
physicians and many, many members at large have
answered forcefully in support of ending the discrimination
in Medicare reimbursement for teaching anesthesiologists.
With the Centers for Medicare & Medicaid Services
(CMS) comment period that ended September 30, 2005,
ASA collectively made a very strong point: Medicare’s
irrational payment policy has had a significant
adverse impact on the ability of academic programs
to train the anesthesiologists necessary to help
alleviate the widely acknowledged shortage of anesthesia
professionals — a shortage that will be exacerbated
in coming years by the aging of the baby boom generation
and their need for surgical services.
With this combined action, ASA, working closely
with the Society of Academic Anesthesiology Chairs/
American Association of Anesthesiology Program Directors
and many others in the academic community and beyond,
is firmly on record with the federal government
in opposition to the 1995 CMS policy change that
has shortchanged academic programs by millions of
dollars over the last decade and threatened the
very future of anesthesiology. ASA is particularly
grateful for the strong support it has received
from across medicine in similar comments from the
American Medical Association, the American Osteopathic
Association, the Association of American Medical
Colleges and a large cross-section of the surgical
and surgical subspecialty community, most notably
from the American College of Surgeons, the American
Association of Neurological Surgeons, the American
Academy of Otolaryngology-Head and Neck Surgery
and the Medical Group Management Association.
As with all academic physician training programs,
teaching anesthesiologists are supposed to be paid
under the Medicare Physician Fee Schedule for their
hands-on training and supervision of medical residents.
For other specialties, particularly surgeons, teaching
physicians frequently work with resident physicians
in overlapping cases and are usually paid a full
fee for each case. For example, a surgeon may supervise
residents in two overlapping operations and collect
a full fee for each case from Medicare. An internal
medicine physician may supervise residents in four
overlapping office visits and collect full fees
for each.
For many years, teaching anesthesiologists were
paid a full fee when working with two residents
on overlapping cases. CMS decided in 1995, as part
of a new Part B teaching payment rule, to revise
the teaching payment policy only as it applied to
anesthesiologists. The resulting inflexible rule
directed Medicare carriers to reduce Medicare payment
by 50 percent per case if a teaching anesthesiologist
works with two residents on overlapping cases. This
CMS policy is simply unfair and has caused widespread
hardship.
A recent survey found that the current Medicare
policy is costing programs an average of $400,000
annually. Some programs are losing in excess of
$1 million annually. Many programs are having
difficulty filling faculty positions and are operating
on negative revenue margins. The 50-percent payment
reduction has become even more problematic as commercial
insurers have begun to adopt the policy when their
beneficiaries receive care in academic institutions.
Make no mistake about it, fixing the Medicare anesthesiology
teaching rule is a defining issue for ASA and academic
medicine. Those who oppose us are gambling with
the safety of surgical patients, both in the Medicare
program and beyond, today and for years to come.
As the recognized leaders in patient safety, anesthesiologists
cannot sustain their remarkable record of ensuring
safe surgical outcomes for Americans if the very
teaching programs that train future physicians continue
to be dramatically underfunded by Medicare. Far
from our shores, anesthesiologists also have responded
with unparalleled professionalism and patriotism
on the battlefronts in Iraq, filling slots far beyond
those expected to be filled by anesthesiologists
and left vacant by other anesthesia professionals.
It is vitally important that America’s ability
to treat its wounded soldiers in the midst of battle,
today and in the future, not be compromised by Medicare’s
unwillingness to properly fund and train our future
generations of anesthesiologists. Aiding disaster
preparedness on our own soil also will require a
good future supply of physicians, including anesthesiologists.
In the August 8, 2005, proposed rule for the FY
2006 Medicare Physician Fee Schedule, CMS agreed
to review the anesthesiology teaching rule and accept
comments on revisions that would make the rule “more
flexible for teaching anesthesia programs.”
The time for action is now, and all eyes are on
CMS as it moves toward a final Medicare payment
rule for 2006, to be published shortly, where resolution
of this issue is imperative.
ASA has emphatically asked CMS to support academic
anesthesiology programs by applying the policy of
payments for overlapping services consistently across
medical specialties and by eliminating the 50-percent
payment reduction for anesthesiology teaching programs.
This same message has been forcefully delivered
to Capitol Hill and the Bush Administration. On
behalf of your dedicated governmental affairs staff,
our fine ASA officers, committee members and all
those who have worked to bring this issue to the
forefront, “thank you!” We will not
relent, and we will prevail!
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