Lessons Learned in Washington

Paloma Toledo, M.D., President-Elect
ASA Resident Component

hen a man died in ancient Greece, they asked one question: “Did he have passion?”

As anesthesiology residents, we have all chosen to spend three years of our lives training in the art of anesthesia. My question for you is, “Do you have a passion for our profession?” Anesthesiologists have been celebrated for leadership in patient care and safety. Are you willing to fight to protect our ability to care for patients in the future?

In early May, 442 passionate anesthesiologists attended the annual ASA Legislative Conference in Washington, D.C. Of those 442, there were 55 residents representing several states.

This year there were four main issues discussed. The Centers for Medicare & Medicaid Services (CMS) anesthesiology teaching rule, the sustainable growth rate (SGR), the Medicare anesthesia conversion factor and the rural pass-through for anesthesiology. As a resident, you must be informed and passionate about these issues, especially the CMS teaching rule.

In 1994, CMS imposed a new anesthesiology teaching rule. Until 1994 an anesthesia attending could supervise two residents concurrently and bill fully for two cases, assuming the attending was present at the key and critical portions of the procedure and available throughout. This is how other medical specialties, including surgery, medicine and pediatrics, bill for procedures. On January 1, 1994, however, CMS singled out anesthesiology and stated that if an attending anesthesiologist is to supervise two residents, he or she will only be reimbursed for one case, not both. In essence if your attending supervises two residents simultaneously, your department is doing one case for free.

You may ask, what does that mean to me as a resident? I am not responsible for billing. My paycheck comes every two weeks regardless of how my hospital is reimbursed, right? Simple answer: “yes,” but only if your program survives!

Here is the bottom line. This current CMS policy is costing each academic institution (including the hospital that is training you) an average of $400,000 annually. In states with a high proportion of Medicare patients such as Florida and Arizona, the policy costs hospitals close to $1 million a year. Across the country, the impact on anesthesiology in 2005 was estimated to be close to $40 million. In 1991, before this rule was enacted, there were 160 academic training programs. Today there are only 130. Twenty percent of our nation’s anesthesiology training programs have closed. With our nation’s aging population and increasing patient complexity, we are going to need well-trained physician anesthesiologists. If we continue to lose 20 percent of our programs in the next decade, we will not be able to meet the necessary physician demand for our patients.

As resident physicians, the quality of our training depends on the faculty who train us. Academic anesthesiology is in a crisis. Some faculty members are leaving academics for more lucrative private practice jobs. One of the consequences of the decline in reimbursement is that faculty need to spend more time in the operating room to generate revenue and therefore cannot pursue other academic interests such as teaching and research. I have seen faculty who love academics leave my own hospital; I am sure you have seen it at yours. This is a scary trend, and we need to put an end to it. We need strong faculty to train our future academicians to ensure that anesthesiology can continue to be a leader in patient care and safety for the next 100 years.

There are two bills in the U.S. House of Representatives, H.R. 5246 and 5384, the Medicare Teaching Anesthesiology Funding Restoration Act of 2006, which would restore the payment for teaching anesthesiologists to 100 percent for each of two overlapping cases where a resident is supervised. At the Legislative Conference, we learned more about this bill as well as other issues affecting anesthesiologists, which included the SGR, the Medicare anesthesia conversion factor, the rural pass-through, anesthesiologist assistant and nurse anesthetist scope-of-practice, pay for performance and many other issues.

In addition to the didactics and panels, one of the runaway hits of the conference was the strategy session for how to effectively advocate to your congresspersons. Melinda Farris, from Capitol Resources, Washington, D.C., did a phenomenal job driving home what you need to do to get your message across to Congress. As an aside, I must add that the Oscar for “Best Performance” next year will go to Ronald Szabat, J.D., LL.M., Director of Governmental Affairs and General Counsel, for his role as a congressman in the conference role-playing sessions.

On Tuesday evening, we had our first Resident Leadership Seminar, where Tripti C. Kataria, M.D., a previous chair of the ASA Resident Component, gave a presentation on why and how residents should get involved in ASA and the American Medical Association. Other guest speakers at the resident seminar included Mark J. Lema, M.D., Ph.D. (ASA President-Elect), Patricia J. Davidson, M.D. (chair of the Committee on Governmental Affairs) and James L. Becker, M.D. (chair of the Executive Board of the ASA Political Action Committee).

On the last day of the conference, known as “Hill Day,” the 400 anesthesiologists took their newfound knowledge to Capitol Hill. They began the dialogue with their senators, representative and staffers, educating them and garnering support for the issues that directly affect anesthesiologists and patients. Residents played a key role this year as the CMS teaching rule directly impacts our education.

At the end of the conference, the residents all headed home — only they had a new passion for legislative affairs and involvement in governmental affairs. Hopefully one of these residents is in your state and can educate your fellow residents about the issues discussed at the conference. If not, you can learn more on the Web site of the ASA Office of Governmental and Legal affairs at <www.ASAhq.org/government.htm>. Learn more, contact your representatives, and let them know your thoughts. Be proactive in protecting our future. I personally challenge each of you to get involved. Be passionate about our future. Be active, and stay involved — your future depends on it!

I would like to thank our state component societies in Alabama, Arizona, Connecticut, Florida, Georgia, Illinois, Indiana, Iowa, Louisiana, Massachusetts, Minnesota, Mississippi, Nebraska, New Mexico, North Carolina, Ohio, Oklahoma, Oregon, Pennsylvania, Tennessee, Texas, Virginia and West Virginia for sending residents to the ASA Legislative Conference. You are model states; we want to see all 42 states with resident training programs represented next year!

I would also like to thank the ASA Washington Office staff for another great Legislative Conference.

Paloma Toledo, M.D., is a CA-2 Resident Physician, Northwestern University Department of Anesthesiology, Chicago, Illinois.