No Better Time to Get Involved

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

n the past year, I have been impressed with the number of anesthesiology residents who have e-mailed or written members of the ASA Resident Component, either asking for advice on how to get involved in governmental affairs or giving feedback on their interactions with local or national elected officials. What has been most striking to me is the number of interns who contact us, as these are residents who have not yet even started their anesthesiology training.

It is impressive that very early in their careers these residents are appreciating the importance of legislative involvement and are going on to be role models for other residents in their programs (and states). People who get involved in organized medicine early often remain involved, so this is quite promising for the future of ASA. I believe that the reason so many residents are becoming active in the ASA Resident Component is because of the Centers for Medicare & Medicaid Services (CMS) “anesthesiology teaching rule,” which remains one of the primary issues being addressed by our specialty.

Paloma Toledo, M.D., ASA Resident Component President, speaks during the 2007 Legislative Conference.

IIn 1994, CMS introduced the anesthesiology teaching rule. Until 1994, an attending anesthesiologist could supervise two residents concurrently and bill fully for two cases, assuming that the attending was present during the key portions of the procedure and available throughout the procedure. This is how surgery bills for procedures, whereas medicine and pediatric attendings can supervise four residents and be paid in full for all four Medicare visits.

On January 1, 1994, CMS singled out anesthesiology and stated that if an attending anesthesiologist is to supervise two residents, they 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.

The bottom line is that this current CMS policy costs each academic institution (including the hospital that is training you) an average of $400,000 annually. In states where there are a high proportion of Medicare patients, such as Florida and Arizona, it costs academic hospitals close to $1 million a year. Across the country, the impact to anesthesiology in 2005 was estimated to be close to $40 million.

In 1991 before this rule was enacted, there were 160 academic training programs. Since then, 20 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 demand for physicians.

Aside from the fiscal problem, this could possibly lead to a teaching problem. In addition to having fewer residents due to the closure of anesthesiology training programs, we will continue to see the loss of anesthesiology faculty who will leave academic anesthesiology due to financial pressures or loss of nonclinical time. The generation of anesthesiology residents who follows us may not have as many faculty who are dedicated and passionate about teaching residents. The people who will ultimately pay the price are our patients, as there will not be enough well-trained anesthesiologists to care for them.

Last year ASA was very close to having legislation that would reverse the CMS teaching rule. ASA residents across the country were extremely active in e-mailing and calling their congresspersons and expressing how important reversing this regulation is for our specialty. The bill last year (H.R. 5246/S. 2990) did become part of a larger Medicare sustainable growth rate and tax-cut package; at the eleventh hour, however, this language was dropped by the previous chair of the House Ways and Means Committee, largely due to intervention from the American Association of Nurse Anesthetists (AANA). This was extremely disappointing, but we learned that residents are interested in the future of anesthesiology and were willing to step up to the challenge, step out of their comfort zones and call or e-mail their congresspersons to get ASA’s message across.

This year there is a new opportunity. Representative Xavier Becerra (D-CA) has introduced H.R. 2053, legislation that would restore full payment to anesthesiology training programs. The language of this bill mirrors H.R. 5246/H.R. 5348 from last year’s Congress. I expect that residents, once again, will continue to play an active role in lobbying for change in the CMS teaching rule.

One obstacle that may be encountered this year is that the nurse anesthetists also have crafted a teaching rule bill, H.R. 1932, which in addition to addressing the teaching rule also implements payment policies for nurse anesthesia programs that will effectively partially fund nurse anesthesia training. As the number of nurse anesthesia training programs are increasing in number nationally, it is hard to understand how their arguments hold any water. Nurse anesthetists are trying to blur the lines between resident physicians — who have spent eight years in medical training — with nurse anesthetists who spend two years in nurse anesthesia training. Part of the work we as residents have to do entails teaching our congresspersons the differences between nurses and physicians.

In conclusion, there is no better time for residents to get involved in ASA and in governmental affairs. Please e-mail your congresspersons today and have every resident in your program do the same. It is easy using ASA’s capwiz program. After entering your ZIP code and clicking a link, a pre-written letter with all of the main talking points on the CMS teaching rule is ready for you. It can be found at capwiz.com/asa/issues/alert/?alertid=9688126&PROCESS=Take+Action. Also, if you have not already donated, make sure to contribute to the ASA Political Action Committee so that our incredible lobbyists can contribute to work on our behalf on Capitol Hill. If every single one of the 6,000 anesthesiology residents spoke as a unified voice on this issue, this may be the last article you ever read about the CMS teaching rule.

Be active and stay involved. Your future depends on it!

More than 60 members of the ASA Resident Component participated in the 2007 ASA Legislative Conference, a record for resident attendance.

Paloma Toledo, M.D., is an Obstetric Anesthesia Fellow, Department of Anesthesiology, McGaw Medical Center, Northwestern University, Chicago, Illinois.