CMS Fails to Address Need for Fix of Anesthesiology Teaching Payment Penalty in 2006 Rule

Despite a massive and well-orchestrated campaign by ASA working closely with SAAC/AAPD to supply formal comments and data, CMS has failed to make needed changes in the Medicare teaching payment rule at this time. CMS declined to eliminate the payment penalty but stated that the agency will “continue to review the information and relevant data presented by the commenters.” ASA will continue its advocacy efforts to eliminate this unfair payment penalty that is causing great harm to the nation’s academic anesthesiology programs.

Federal Register

F. Payment for Teaching Anesthesiologists

In the August 8, 2005 PFS proposed rule (70 FR 45789), we summarized the current policy for the payment for services provided by teaching anesthesiologists, including the revisions to the policy published November 7, 2003 (68 FR 63196 through 63395), where we revised §414.46 of our regulations to allow teaching anesthesiologists to bill in a similar manner to teaching certified registered nurse anesthetists (CRNAs) for the teaching anesthesiologist's involvement in two concurrent cases involving residents. This policy took effect for services furnished on or after January 1, 2004 and was intended as an alternative to the "medical direction" payment policy applicable to concurrent cases involving teaching anesthesiologists and residents.

As noted in the August 8, 2005 proposed rule, despite the higher level of payment available under this policy, the American Society of Anesthesiologists (ASA) has informed us that it is not aware of any teaching anesthesia programs that have arranged their practices to meet the conditions necessary to bill under the revised policy. The ASA suggests that the teaching physician regulations for teaching anesthesiologists should be similar to those for teaching surgeons for overlapping complex surgery procedures. The ASA thinks that anesthesia is similar to complex surgery in terms of critical periods, overlap, and availability of teaching physicians. However, as we noted in the August 8, 2005 proposed rule, the critical portions of the teaching anesthesia service and the critical portions of the teaching surgeon service are not the same. The ASA believes that inadequate payment levels have contributed to the loss of teaching anesthesiologists and an inability to recruit new faculty.

In the August 8, 2005 proposed rule, we requested comments on a teaching physician policy for anesthesiologists that could build on the policy announced in the November 7, 2003 PFS final rule, but could provide the appropriate revisions that would allow it to be more flexible for teaching anesthesia programs. We also indicated we would be interested in receiving data and studies relevant to this issue as well as any offsetting savings that could be made to account for any potential costs that could be incurred if there was a policy change.

Discussion of Comments Received

As discussed previously in this section, we did not present a formal proposal, but asked for comments from interested stakeholders on these issues. While we have not fully analyzed all the relevant information and data, we have been provided anecdotal evidence that some anesthesiologists may be leaving academic practice for better compensated positions in private practice. While we recognize that Medicare payment policies are an important consideration in these decisions, they are not the only factor.

In contrast, as pointed out by a commenter, there has been an increase in the number of nurse anesthesia programs from 83 programs in 2000 to 105 programs projected for 2006. The number of nurse anesthesia graduates has surged from 1075 nurse anesthetists in 2000 to 2035 projected for 2006. Despite these increases, nurse anesthesia programs had reported similar financial problems, such as levels of teachers' salaries, in recruiting faculty to teaching nurse anesthetists.

In terms of anesthesia manpower, we did not receive any information from surgical groups indicating difficulty in getting anesthesiologists or CRNAs to provide anesthesia services. Additionally, we did not receive any comments identifying areas of offsetting savings that might be used to fund any change in the teaching anesthesia payment policy.

We will continue to review the information and relevant data presented by the commenters and consult with the stakeholders before we move for ward with any proposal.