The Impact of Legislation The Impact of Legislation on Anesthesia Practiceon Anesthesia Practice

Is Political Activism Optional?Is Political Activism Optional?

Anne T. Lunney, M.D.Anne T. Lunney, M.D.

University of North CarolinaUniversity of North Carolina

UNC / Lunney

Considerations of the Average Considerations of the Average ResidentResident

As we transition from trainee to As we transition from trainee to consultant we will consider many consultant we will consider many variables when considering our first variables when considering our first positionposition GeographyGeography Hospital and its milieuHospital and its milieu ContractsContracts Partnership tractPartnership tract

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Also Important to Consider…Also Important to Consider…

Payer mixPayer mix now, and in the futurenow, and in the future Relationship with CRNA’s and AA’sRelationship with CRNA’s and AA’s Liability environment within the StateLiability environment within the State State legislation which supports or State legislation which supports or

protects practice and/or protects practice and/or reimbursementreimbursement

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AllAll Are Influenced by Legislation Are Influenced by Legislation

Payer mixPayer mix Medicare and Medicaid reimbursementMedicare and Medicaid reimbursement

Relationship with CRNA’s and AA’sRelationship with CRNA’s and AA’s CRNA and AA scope of practice and CRNA and AA scope of practice and

reimbursementreimbursement Malpractice and liabilityMalpractice and liability

Tort reformTort reform

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Who is Advocating for Who is Advocating for AnesthesiologistsAnesthesiologists

Anesthesiologist and Anesthesia Anesthesiologist and Anesthesia ResidentsResidents

American Society of American Society of AnesthesiologistsAnesthesiologists

State anesthesia societiesState anesthesia societies National and state ASA PACsNational and state ASA PACs The American Medical AssociationThe American Medical Association LegislatorsLegislators

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ASAASA

Pro-physician, pro-anesthesia, pro-Pro-physician, pro-anesthesia, pro-patient safetypatient safety

Educate anesthesiologists, Educate anesthesiologists, legislators, and the general publiclegislators, and the general public

Propose legislation and find Propose legislation and find representatives who will sponsor and representatives who will sponsor and support said legislationsupport said legislation

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Political Action CommitteePolitical Action Committee

PACs serve the interests of their PACs serve the interests of their constituentsconstituents

Pooling of fundsPooling of funds Collective effortCollective effort Unified voiceUnified voice Support specific legislation and Support specific legislation and

legislators at the state and national legislators at the state and national levellevel

LobbyLobby

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The Issue’sThe Issue’s

Teaching RuleTeaching Rule Reimbursement ParityReimbursement Parity Sustained growth rate formulaSustained growth rate formula Gubernatorial supervisory opt outGubernatorial supervisory opt out Rural pass throughRural pass through CRNA scope of practice legislation CRNA scope of practice legislation Tort reformTort reform

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Teaching RuleTeaching Rule

1991 Medicare regulatory change, 1991 Medicare regulatory change, instituted in 1994 instituted in 1994

Anesthesiology teaching faculty Medicare Anesthesiology teaching faculty Medicare reimbursement is decreased by 50% if the reimbursement is decreased by 50% if the teaching faculty is supervising more than teaching faculty is supervising more than one resident when caring for Medicare one resident when caring for Medicare patientspatients

Private insurance companies are starting Private insurance companies are starting to reimburse teaching physicians in a to reimburse teaching physicians in a similar fashionsimilar fashion

Not applied to any other teaching Not applied to any other teaching physiciansphysicians, including surgeons, including surgeons

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Teaching RuleTeaching Rule

Since the institution of this Medicare Since the institution of this Medicare regulation, the number of regulation, the number of Anesthesiology residency programs Anesthesiology residency programs has decreased from approximately has decreased from approximately 160 to 130 programs160 to 130 programs

Costs Academic Anesthesiology Costs Academic Anesthesiology departments $400,000+ per yeardepartments $400,000+ per year

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Teaching RuleTeaching Rule

HB 5246 introduced by House HB 5246 introduced by House Representatives Shaw and Sessions Representatives Shaw and Sessions in May of 2006in May of 2006

Medicare teaching anesthesiology Medicare teaching anesthesiology funding restoration actfunding restoration act Fashioned to reverse the 1991 Fashioned to reverse the 1991

regulatory changeregulatory change Similar legislation to follow in the Similar legislation to follow in the

SenateSenate

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Reimbursement ParityReimbursement Parity

1992 – Medicare fee schedule for 1992 – Medicare fee schedule for reimbursement of anesthesiology reimbursement of anesthesiology servicesservices

The conversion factor using absolute The conversion factor using absolute dollars is paying < 80% of what it was in dollars is paying < 80% of what it was in 19911991

<40%<40% of what is paid by private insurers of what is paid by private insurers Other specialties reimbursed Other specialties reimbursed ~ 80% ~ 80% of of

what is paid by private insurerswhat is paid by private insurers

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Reimbursement ParityReimbursement Parity

ASA is providing the General ASA is providing the General Accounting Office with information on Accounting Office with information on the disparity between private the disparity between private insurance reimbursement and insurance reimbursement and Medicare reimbursementMedicare reimbursement

The evaluation is an undertaking of the The evaluation is an undertaking of the ways and means subcommittee and is ways and means subcommittee and is supported by House Representatives supported by House Representatives Nancy Johnson and Pete StarkNancy Johnson and Pete Stark

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MedicareMedicareSustained Growth Rate FormulaSustained Growth Rate Formula

Medicare part BMedicare part B 2007 projected cut of 4.6%2007 projected cut of 4.6% Projected average annual cut of 5% from Projected average annual cut of 5% from

the years 2007 to 2012the years 2007 to 2012 Cut averted annually with stop-gap Cut averted annually with stop-gap

measuresmeasures We are fighting simply to prevent annual cuts, We are fighting simply to prevent annual cuts,

rather than supporting a reimbursement rather than supporting a reimbursement system that is consistent with the cost of system that is consistent with the cost of delivering caredelivering care

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SGRSGRAlso influenced byAlso influenced by

Drug payment is grouped into Drug payment is grouped into the physicians services funding the physicians services funding poolpool The cost of medication is steadily The cost of medication is steadily

increasing and thus decreasing the increasing and thus decreasing the ability to fairly reimburse physiciansability to fairly reimburse physicians

The cost of physician services are The cost of physician services are increased with the institution of any increased with the institution of any state or national regulatory changestate or national regulatory change

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SGRSGR

The Medicare payment advisory commission The Medicare payment advisory commission (medPAC) recommended reimbursement (medPAC) recommended reimbursement requiring an estimation of changes in input requiring an estimation of changes in input for the coming year, less an adjustment for for the coming year, less an adjustment for growth in multifactorial productivitygrowth in multifactorial productivity

The Medicare Economic Index (MEI) is The Medicare Economic Index (MEI) is similar to the current paymentsimilar to the current payment update update formula utilized for hospitals, Nursing formula utilized for hospitals, Nursing homes, and other medicare providers which homes, and other medicare providers which are based on practice cost increasesare based on practice cost increases

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SGRSGR

HR 3617HR 3617 Introduced by House Representative Introduced by House Representative

Nancy JohnsonNancy Johnson Repeal the SGR formula and replace it Repeal the SGR formula and replace it

with a MEI reimbursement adjustment with a MEI reimbursement adjustment mechanismmechanism

Parity with services other than Parity with services other than physicians that are reimbursed by physicians that are reimbursed by MedicareMedicare

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Supervision Opt OutSupervision Opt Out

2001 - ruling on Medicare and Medicaid 2001 - ruling on Medicare and Medicaid regarding anesthesia conditions of regarding anesthesia conditions of participation for critical access hospitals participation for critical access hospitals and ambulatory surgical centersand ambulatory surgical centers

Governors can opt out of the national Governors can opt out of the national standard of supervision of CRNA’sstandard of supervision of CRNA’s

Outcome studies on unsupervised CRNA’sOutcome studies on unsupervised CRNA’s 25 more deaths per 10,000 medicare patients25 more deaths per 10,000 medicare patients

Limitation of surgery in rural areas isLimitation of surgery in rural areas is not not limited by Anesthesia limitationslimited by Anesthesia limitations

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Supervision Opt OutSupervision Opt Out

Reimbursement is the same under Reimbursement is the same under Medicare forMedicare for Anesthesiologist (100% to MD)Anesthesiologist (100% to MD) Anesthesiologist supervising a CRNA Anesthesiologist supervising a CRNA

(50%CRNA:50%MD)(50%CRNA:50%MD) Surgeon supervising a CRNA (100%CRNA)Surgeon supervising a CRNA (100%CRNA) CRNA practicing without supervision CRNA practicing without supervision

(100%CRNA)(100%CRNA) Financial incentiveFinancial incentive

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Rural Pass ThroughRural Pass Through

Medicare part BMedicare part B Reimbursement for AnesthesiologistsReimbursement for Anesthesiologists

Rural hospitals with surgical caseloadsRural hospitals with surgical caseloads

< 800 per annum reimbursed via < 800 per annum reimbursed via Medicare part AMedicare part A

Rural pass through to CRNAs and AAs Rural pass through to CRNAs and AAs onlyonly

Extend exception to include Extend exception to include Anesthesiologists!Anesthesiologists!

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Scope of Practice – CRNA’s Scope of Practice – CRNA’s

CRNA’s and AA’s are not trained to make CRNA’s and AA’s are not trained to make medical judgmentsmedical judgments

Direct and immediate supervision or the Direct and immediate supervision or the existence of a protocol/collaborative existence of a protocol/collaborative arrangement with a physicianarrangement with a physician

Credentialing of CRNA’s should take Credentialing of CRNA’s should take practice environment into account and they practice environment into account and they should not be credentialed to perform should not be credentialed to perform medical diagnostic assessment, indications, medical diagnostic assessment, indications, contraindications and treatment in response contraindications and treatment in response to complications that require medical skill to complications that require medical skill and judgementand judgement

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Tort ReformTort Reform

Physicians leaving or curtailing their Physicians leaving or curtailing their practicepractice

Defensive medicine – 60 billion per yearDefensive medicine – 60 billion per year Medical liability increase 750% since Medical liability increase 750% since

19751975 Compared with 245% increase in CaliforniaCompared with 245% increase in California 1975 California Medical Injury 1975 California Medical Injury

Compensation Reform Act (MICRA)Compensation Reform Act (MICRA)

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Tort ReformTort ReformMICRAMICRA

Recover unlimited economic damagesRecover unlimited economic damages $250,000 limit on noneconomic $250,000 limit on noneconomic

damagesdamages $250,000 limit on punitive damages or $250,000 limit on punitive damages or

2X economic damages – clear and 2X economic damages – clear and convincing evidence of malicious intentconvincing evidence of malicious intent

Allocation of damages of multiple Allocation of damages of multiple defendants proportional to faultdefendants proportional to fault

Limits on contingency fees that may be Limits on contingency fees that may be charged to plaintiffscharged to plaintiffs

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Tort ReformTort Reform

S. 22S. 22 Medical care access protection act of Medical care access protection act of

20062006 Comprehensive medical liability reform Comprehensive medical liability reform

modeled on MICRAmodeled on MICRA S. 23 S. 23 Healthy mothers and healthy babies Healthy mothers and healthy babies

access to care actaccess to care act Targeted medical liability reformTargeted medical liability reform

UNC / Lunney

What can you do?What can you do?

Understand the issues that affect your Understand the issues that affect your practice at both the state and practice at both the state and national levelnational level The ASA and the ASAPAC is an excellent The ASA and the ASAPAC is an excellent

source of updated informationsource of updated information The ASA website has all of the key issues The ASA website has all of the key issues

from the May 2006 meeting outlinedfrom the May 2006 meeting outlined Start small rather than not at allStart small rather than not at all

Pick a single issue that you feels strongly Pick a single issue that you feels strongly about about

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What can you do?What can you do?

Speak outSpeak out Specific legislation that is currently Specific legislation that is currently

active and needs support active and needs support nownow is HR is HR 5246 (rectifying the teaching rule), 5246 (rectifying the teaching rule), and S. 22 and S 23 (tort reform)and S. 22 and S 23 (tort reform) Write to your legislators – LobbyWrite to your legislators – Lobby

Express your feelings and share your Express your feelings and share your knowledge about a specific piece of knowledge about a specific piece of legislation you would like them to supportlegislation you would like them to support

Thank them for legislation they have Thank them for legislation they have supportedsupported

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What can you do?What can you do?

Join state and national Join state and national anesthesiology and medical anesthesiology and medical associations associations

Residents can join the national and Residents can join the national and state PACs for as little as $25state PACs for as little as $25

Remember if all residents gave $25, Remember if all residents gave $25, it would really add up!!!!!!!!it would really add up!!!!!!!!

UNC / Lunney

RememberRemember

If the collective Anesthesiology voice If the collective Anesthesiology voice is not heard,is not heard, Decisions will be Decisions will be made made without your inputwithout your input

And, decisions And, decisions will be made with the will be made with the input of the oppositioninput of the opposition Insurance companiesInsurance companies AANAAANA The Center for Medicare and Medicaid The Center for Medicare and Medicaid

Services (CMS)Services (CMS)

UNC / Lunney

Thank YouThank You

Be educatedBe educated Be activeBe active Or….support the organizations who Or….support the organizations who

are working on your behalfare working on your behalf

OUROUR FUTURE IS IN FUTURE IS IN OUR OUR HANDSHANDS