Douglas R. Bacon, M.D., Editor

Henry Kissinger and P4P

What is the utility of studying history?

It is a simple question without a clear answer. The most sophisticated scholars often respond along the lines of Henry Kissinger, who said in his book The White House Years:

History is not, of course, a cookbook offering recipes. It teaches by analogy, not by maxims. It can illuminate the consequences of actions in comparable situations, yet each generation must discover for itself what situations are in fact comparable.

ASA and all anesthesiologists are faced with a challenge. Pay for performance, or P4P, is one of the new buzzwords or, if you will, buzz concepts running around Washington, D.C. The idea is straightforward — pay physicians for performing at or above a preset standard. In theory this should increase the quality of care for all patients, especially Medicare patients, for whom the federal government has the power to impose changes in reimbursement. Medicare, however, is often used as an example for private health insurers. P4P is so simple, and having been used in a variety of settings outside of health care, it seems to be the “ticket” to decrease medical errors and make the delivery of health care safer and more cost-effective.

Like all panaceas, the devil remains in the details. What standards are imposed are critically important. Checking for an insulin order for each blood sugar over a certain value is a relatively painless and easy standard to meet, which may or may not have real medical significance, whereas ensuring less than a 20-percent drop in blood pressure on induction of all patients may be well nigh impossible. Thus the creation of the standards is vitally important and needs to be done, for anesthesia, with an understanding of anesthetic action and the entire perioperative experience.

The question before ASA and the anesthesiology community as a whole is: At what level do we wish to participate? In recent issues of the ASA NEWSLETTER, strong opinions in letters to the editor on both sides of the issue have been expressed. Our officers need to make our position known to many people in Washington, but they cannot do this without a consensus of the membership, which is reflected in the deliberations of the Board of Directors and the House of Delegates. In my view, there are two possible positions, both reflected within the history of ASA.

The first stance is not to cooperate with P4P and fight the government tooth and nail through all possible venues, including the court system. Historically one of the greatest chapters in ASA history was written by taking just such a stance. The Relative Value Guide (RVG) was developed and implemented in California in the late 1950s. The idea spread and was introduced nationally by ASA in the 1960s. Other specialties adopted the RVG model over the next decade and a half. By September 1975, the Department of Justice had filed an antitrust suit against the New York State Society of Anesthesiologists and consequently ASA, charging that the RVG essentially fixed prices and did not allow competition. RVG action also was taken against the American Academy of Orthopaedic Surgeons, the American College of Obstetricians and Gynecologists, the American College of Radiology and the Minnesota Medical Association. These organizations capitulated and accepted a cease and desist order dictated by the Justice Department.¹

ASA stood alone against the might of the United States government. Most importantly ASA’s legal counsel believed that there was a better than 50-percent chance that the suit could be won by ASA. The House of Delegates resolved that there would be no compromise with the Justice Department and voted a substantial sum to cover legal expenses. The case was heard before Judge Kevin T. Duffy in New York City between November 20 and December 4, 1978. More than six months later, on June 22, 1979, the decision was issued, with the judge finding that the ASA RVG did not violate the antitrust laws and therefore dismissed the suit. ASA had stood alone and won — a clear historical lesson in the importance of standing up for the values important to the organization.

The second historical example relates the importance of working with rather than against the federal government. In 1961 the King-Anderson bill came before the House of Representatives for debate. The bill dealt with the federal government’s payment to those receiving Social Security of a substantial percentage of hospitals costs. The bill did not cover payment for physician services, except for radiologists, pathologists, physiatrists and anesthesiologists who were presumed to be employed by the hospital. While the other three specialists actually wanted to be hospital employees and have their institutions collect fees for them, anesthesiologists wished to be independent of such an arrangement and treated like the rest of the house of medicine. ASA requested and was granted the privilege of presenting testimony before the House Ways and Means Committee. The thrust of the testimony was that most anesthesiologists billed independently as physicians and were not employees of the hospital. ASA President Forrest E. Leffingwell, M.D., was effective before the committee, and the language concerning anesthesiologists was removed from the bill.²

In 1965, as the Medicare Bill was introduced in the Senate, a similar problem arose. Senator Paul Douglas introduced an amendment returning the services of anesthesiologists, along with radiologists, pathologists and physiatrists, to be paid as part of the hospital reimbursement. This time ASA President Perry P. Volpitto, M.D., and Counsel Jack Lansdale testified in front of the Senate Finance Committee. They contrasted the situation with the other specialties to anesthesiology and provided hard data that most anesthesiologists practiced independently much like a surgeon or internist. Mr. Lansdale and Dr. Volpitto also were convinced that the future of anesthesiology would best be served by keeping anesthesiologists as independent physicians. Finally they argued that if anesthesiologists were included in the bill, it would impact negatively on the entire practice of medicine. Perhaps they reasoned that eventually all specialists would become employees of the hospital. By working with the government, ASA was again victorious, and the concept of an anesthesiologist as an independent physician was firmly established.

Here then from ASA history are two examples of how the Society, and anesthesiologists in general, should approach pay for performance. Which is the “correct” paradigm? Are there any clues that may help us figure out what will be the best way to proceed?

First, in both instances, ASA followed the advice of its legal counsel. The words of ASA Director of Governmental Affairs and General Counsel Ronald Szabat, J.D., LL.M., on this issue are and will remain critical to ASA’s position. As anesthesiologists we will not be afforded another chance to “get this right.” Mr. Szabat, along with Vice-President for Professional Affairs Alexander A. Hannenberg, M.D., have been closely monitoring this issue and have written about it in previous editions of the NEWSLETTER. It would be the height of naiveté to believe this issue will go away of its own accord.

It appears as these words are written that the concept is so easy to promote, and that the perceived need for a regulation is so great, that fighting P4P is fruitless. Thus I would argue that the first historical example, standing and fighting the government alone, will lead to failure. The average person will not understand the problems and concerns of implementation of this program; rather they will perceive it as physicians trying to “cover up.” It could even be construed that physicians, especially anesthesiologists leading the fight, do not wish to have public scrutiny of their practice. While this is not the reason to disagree with P4P, perceptions, especially of the general public, are hard to control. Imagine how easy it is to distort any position centered on the concept that the data are meaningless and simply another box to check. Society as a whole could interpret opposition as an unwillingness to increase the standard of care, to undergo scrutiny, rather than the medical opinion it may be.

In the end, ASA needs to work with those responsible for implementing P4P. It will not go away. If it is to have any meaning for anesthesiology, we need to be involved in the conception, planning and implementation of the program. It is far too important to the specialty, to ASA and ultimately to our patients to ignore. Fighting against it will only lead to an impossible system created by bureaucrats who have no understanding of the nature of our practice, the goals that are measurable and obtainable and that ultimately will improve practice, however slight the effect may be. As the long history of ASA suggests, we the members are guardians of the future of the specialty, and as such, it is our duty to advance and protect it.

While P4P may be a passing fad, it has the potential to do great harm. By working with the federal government, we can minimize that effect. The time to do so is now — not to act may well have fatal consequences for our beloved specialty.

— D.R.B.

References:
1. Gotta AW. The 1970s: A decade of crisis. In: Bacon DR, Lema MJ, McGoldrick KE. (eds.) The American Society of Anesthesiologists: A Century of Challenges and Progress. Park Ridge, IL: Wood Library-Museum of Anesthesiology. 2005:147-157.

2. Ogunnaike B, Giescke AH. The 1960s—the ASA comes of age. In: Bacon DR, Lema MJ, McGoldrick KE. (eds.) The American Society of Anesthesiologists: A Century of Challenges and Progress. Park Ridge, IL: Wood Library-Museum of Anesthesiology. 2005:103-121.

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