Roger A. Moore, M.D.

n the past, as ASA Treasurer, I found writing NEWSLETTER articles very straightforward. The issues of finance are black and white — increase revenue and decrease expenses. As First Vice-President, however, such clarity is hampered by the challenge of suddenly emerging “tar pits.” These traps seem to be appearing more frequently, leaving us in a gray landscape where little is all black or all white. Anesthesiology is currently under what appears to be a concerted and possibly coordinated attack from many fronts, to an extent we have not previously witnessed. One might think that determining how to deal with these increasingly virulent affronts to our profession would be clear cut and would receive unanimous support, but such is not the case — ergo, the gray zone.

Several bubbling tar pit issues have risen to the surface in just the past six months. The huge 8.9-percent slash in the Medicare conversion factor for anesthesia is one example, though significant increases in reimbursement for critical care service and pain medicine will mitigate some of that shortfall for practices actively engaged in these subspecialty services. Additionally our intensive work with the American Medical Association (AMA) to legislatively reverse the 5-percent sustainable growth rate reduction averted the initially proposed 13.9-percent cut, but we are still faced with a significant decrease. So what are we doing, and what should we do?

Certainly the displeasure of ASA has been transmitted formally to the Centers for Medicare & Medicaid Services (CMS). By working with the Relative Value Update Committee (RUC), as well as direct intervention with CMS, we will attempt to reverse some or most of this devastating reduction. With Medicare heading toward bankruptcy, however, it is more likely than not that our petitions will face stiff resistance. ASA cannot simply propose some sort of collective action by our members as a way of getting the attention of CMS, because doing so could violate antitrust constraints and severely impact ASA. One potential path ASA could explore is evaluating the development of an Anesthesiologists’ Union, which would be allowed to negotiate collectively with insurance companies and governmental agencies without antitrust concerns; but existing labor laws allow only employed, nonsupervisory personnel to unionize, as AMA found out after spending tens of millions of dollars. In addition seeking antitrust relief through legislative efforts also is being re-evaluated and seems our most promising means of attack. Such actions certainly should be explored but may meet resistance from managed care entities that would keep us within the gray zone.

One particularly “stinky” tar pit is the shooting down of the anesthesiologist teaching rule. We have been informed that in the last hour before Congress adjourned in December 2006, intense and highly targeted lobbying from the American Association of Nurse Anesthetists resulted in the removal of our bill from the Medicare and tax package. ASA President Mark J. Lema, M.D., Ph.D., addressed our disappointment over this in a previous NEWSLETTER article, and he is the originator of the appropriate term, “stinks.”

What should be our response? Of course we will try again with a new Congress and another fix-it bill. Most of us understand how critical the health and well-being of our residency programs are for our future. We do, however, have dissenters within our ranks saying that the political time and effort spent on this bill diverted our attention from more important issues that would have helped private practitioners. I have to respond that ASA leadership is concerned about all anesthesiologists in every mode of practice, but keeping our academic programs viable is a must for the future of our profession and the safety and well-being of our patients. We have lost 30 core and subspecialty residency programs in the past 15 years, and continued loss of training programs will severely impact all areas of care in our specialty.

Also bubbling within the mire of the tar pit is the whole arena of pay for performance (P4P). AMA President William Plested III, M.D., strongly argues that P4P is yet another boondoggle and that physicians should resist it. Just as adamant on the other side of the argument is U.S. Department of Health and Human Services Secretary Michael Leavitt, M.D., who threatens, “If the M.D.s don’t do it, the M.B.A.s will.” Industry, CMS and a number of medical societies have all climbed aboard this train. Should we walk away or climb aboard also and at least see where it’s heading? If this train leaves the station without ASA, our members will likely see even more severe cuts in Medicare reimbursement in the future. For the moment, ASA has taken the stance of cautious involvement in the process with the hope that it will pay off in future dividends for our members. This, though, remains a tar pit sitting squarely in the gray zone.

Our path is hampered by other components of the tar pit, particularly the continuing trend of insurance companies, recently focused on anesthesiology, ignoring the primacy of the physician in making medical necessity decisions. This issue was brought to the surface when Aetna decided to deny payment for deep sedation during colonoscopy for a large segment of their insured population. Let it be clearly stated that having an insurance company dictate medical necessity based on a desire to cut costs and preserve stockholder returns is unconscionable for both patients and physicians.

What role should ASA leadership play in fighting this? We could entirely ignore the policy, but then we leave each anesthesiologist having to fight with the health plans to make the best deal. We could have a massive and expensive media campaign against those health plans at fault and suggest that the insured switch to a different company, but this would clearly violate antitrust laws. We could try to lobby for federal legislation to prevent health plans from making these decisions, but our Washington Office notes that past efforts along these lines by all of medicine have fallen short of success. Or we could approach the health plans directly to provide information and attempt to influence them to modify their plan in a way that would improve coverage and preserve quality of care. Based on a 2003 survey of the ASA House of Delegates (HOD) placing economic advocacy as the number-one priority for ASA leadership, ASA chose to deal directly with this poor policy by making suggestions for improvement through the efforts of our Committee on Economics. Although the modifications did not meet the goals set, the result was far better than the original proposal. This modest success, however, was not without ramifications. Sometimes it is necessary to get into the pit to fight the battle, and in this case, ASA got splattered with tar. Unfortunately there were some members of ASA who were more than willing to supply the feathers as a way to vent their understandable anger and frustration over this whole situation.

So what is my perspective on all this? As a part of the ASA leadership, I can honestly say that the job of the officers is to WORK FOR YOU. We take our direction through the representative process of our HOD and Board of Directors. As with any group, opinions can vary, but the other officers and I make every attempt to do what we think is best for the greatest portion of our membership and for the future of our specialty. This often means making decisions in the gray zone, where no clear-cut path exists. If you feel we are going in the wrong direction, your recourse is to offer a direction change with a resolution in the HOD that gives us the needed direction. We need your continued support and involvement. To borrow a phrase from AMA, “Together we are stronger!”

I look forward to working with each of you over the coming years as we navigate a gray landscape full of tar pits! I know I speak for all of the officers when I say we welcome all input, but please put the feathers away!

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