o matter how old you are or how time may fly, 100 years is still a long time. And, needless to say, a lot has changed, especially in Washington, D.C. In fact, the very nature of our federal government and how physicians can and must relate to it continues to evolve.

Cooling Off
A century ago, modern air conditioning was just being invented, but official Washington still mostly shut down in the long summer months so that our U.S. Representatives and Senators could travel home and avoid the swampy, hot and steamy weather along the Potomac River. By historical accounts, the House chamber was first “cooled” in 1928, and the Senate was “air conditioned” in 1929. Not so for the average worker in Washington, but vast federal agencies still were few and far between, and “the bureaucracy” of career civil servants was miniscule by current standards.

U.S. House of Representatives, circa 1929.

In the first half of the last century, it is hard to think of many items involving the reach of the federal government, particularly those affecting all of medicine, or anesthesiology in particular, that could not wait until cooler fall weather. In fact the very growth of government in Washington waited until some 50-plus years ago and followed World War II and the dramatic growth of federal programs such as Social Security and further social experiments such as the creation of Medicare in 1965.

On The Move
Transportation, too, was difficult and much slower as the 20th century began. When ASA was founded, trains were the order of the day for long travel, and only in 1908 was the Ford Model T introduced. More obviously, there was no hourly airline “shuttle” service to New York and other cities. Close in National Airport (much later renamed to honor President Ronald Wilson Reagan), was still mudflats on a bend of the Potomac River at Gravelly Point, not far from the Abingdon mansion, birthplace of Eleanor “Nelly” Parke Custis, stepdaughter of President George Washington. It was not until President Franklin Delano Roosevelt intervened that Congress was forced to move ahead with the building of this Washington transit landmark. Today many visitors to Washington come and go by jets every few minutes, alongside the very members of Congress who have come to be expected to travel back and forth to their districts on a weekly basis.

Lines of Communication
The communication revolution also has gone hand-in-hand with advances in medical technology. Telephone service, growing by leaps and bounds through much of the 50 years following ASA’s founding, made everyday contacts between constituents and elected officials faster and increasingly cheaper through the present. Fax machines in the last 20 years made more detailed communications possible as have computers and handheld devices such as today’s Blackberrys and PalmPilots. The “Information Age” saw its nearly invisible roots begin when ASA was young, but its increasingly sophisticated technology now has established the means for ensuring that our message from anesthesiology successfully competes for attention with all the other signals crossing a congressional or federal government entity’s electronic threshold on a daily basis.

Clearly, what was the norm is no longer the norm. Visitors to ASA’s Washington Office stop and marvel at the vintage anesthesia-delivery equipment in our “Eastern Annex” to the Wood Library-Museum of Anesthesiology. These are the relics from our first 100 years. In contrast it is important that we also marvel at the skill and sophistication in the way in which our ASA members and advocacy staff fight to get anesthesiology’s message to Congress and the federal agencies.

The very growth of federal payment for medical services since Medicare’s inception and the ratcheting down of such reimbursement through the resource-based relative value system (RBRVS) and Relative Value Guide since 1992, and more recent unworkable artifices such as the sustainable growth rate (SGR), should cause every ASA member to stand up and get involved. Government price-setting for medical care and all its related regulations were virtually unknown before Medicare. Unfortunately this complexity is not going away, no matter what we wish. Congress and the Administration can and must be contacted and lobbied on a continual basis to correct their misconceptions about medical practice and to keep the regulators in check. This is what your Washington Office does on a daily basis, but we cannot get the whole job done alone. The battles of the recent past — protecting Medicare supervision requirements, preventing anticipated payment/diagnostic related groups (RAP DRGs) and other high-profile legislative fights — would not have been won without the concerted efforts of our ASA members working together.

So, too, our ASA has succeeded in calming over-regulation of anesthesiology through strong advocacy. Among ASA’s key victories was the inclusion, in the 1989 legislation that launched the Medicare Fee Schedule and the RBRVS, of the requirement that Medicare payments for anesthesia services be based on the ASA Relative Value Guide. In 1991, when the Medicare agency was writing the regulations implementing the Fee Schedule, it sought to impose an average time-based system on anesthesia. Together we persuaded them to retain actual anesthesia time in the formula.

Time came under attack again when the Health Insurance Portability and Accountability Act standards for electronic claims were under development. The commercial payer community fought hard to require anesthesiologists to report total minutes rather than units so that private payers and Medicare might be able to reduce payment on the last unit of time. We cultivated allies in the American Medical Association and elsewhere and made the case for retaining the option to bill time units — saving the specialty about $128 million per year. This is once again being challenged by the payers, and, as we did several years ago, the Washington Office may soon ask for our members’ help through individual letters to the Centers for Medicare & Medicaid Services (CMS).

You can see that federal agencies — not just CMS, but also others such as the Food and Drug Administration — are a font of regulations that would control even more of your practice if we were not constantly vigilant. The locked anesthesia carts and the postanesthesia follow-up note issues appear now to be behind us. There is no telling what will be next, only that there will be a new regulatory challenge in front of us soon.

The ASA Political Action Committee is the largest medical specialty political action committee in the United States. The ASAPAC booth is a popular stop at the ASA Annual Meetings.

The Future Is Now!
If you have not checked out our ASA position papers and recently contacted your elected representatives or CMS by fax, telephone and e-mail, you are not helping ASA help you. Old-fashioned letters are just that — old-fashioned and destined for a time-consuming trip to “irradiation” plants in Ohio before delivery to Capitol Hill and other agencies. The modern age demands both electronic messages and good “old-fashioned” personal visits with our legislators. More than 400 leaders from across our state component societies did just that in May 2005. Right now every other ASA member should check out our position papers at <www.ASAhq.org/Washington/pospapers.htm> and follow suit with messages and visits

Only your active involvement in the political side of medicine, and anesthesiology in particular, will ensure that the profession thrives for another 100 years and beyond! Your anesthesiology practice does not exist in a horse-and-buggy era and neither can our lobbying. Embrace the modern age!

Ronald Szabat, J.D., LL.M., is ASA Director of Governmental and Legal Affairs.

Karin Bierstein, J.D., M.P.H., is ASA Assistant Director of Governmental Affairs (Regulatory).

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