ASA Update SAAC/AAPD November 5, 2005 Orin F. Guidry, M.D. President

ASA UpdateSAAC/AAPDNovember 5, 2005

Orin F. Guidry, M.D.

President

SAAC Meeting ProgramThe Chair’s Job

• What Deans Look for and Expect from Clinical Chairs

• Assessing the Position: What I’ve Learned• Change: You, The Job, Your Environment• Take Care of You

SAAC Meeting ProgramThe Chair’s Business

• Running Our Business• Should Anesthesiology Enter Into RBRVS?• How Reimbursement for Anesthesia Services Is

Determined• Implications of the RBRVS for Academic

Anesthesia• Academic Chairs and Key Professional

Organizations

SAAC Meeting ProgramThe Chair’s Faculty

• Academic Recruitment: Insights From the Pros• Faculty Development in a Busy Clinical

Environment• Everything I Have Learnt About Faculty

Mentoring Over The Last 30 Years!• Clinical Expertise and Educational Excellence:

Avenues for Academic Advancement• Developing Clinician Scientists and Basic

Scientists in a Clinical Department

SAAC Meeting ProgramThe Chair’s Teaching Program

• Linking Outcomes of Care to the ACGME Core Competencies

• Status of the 4-Year Curriculum• Training the Anesthesiologist of the Future

Academic Anesthesiology Problems

• Financial Issues – the Teaching Rule

• Manpower Issues – Clinical Demand

• Lack of Academic Output

• Unreasonable Expectations

• Training Not Geared to the Future

• Ineffective in Influencing the Future

ASA Initiatives

• Governance Changes

• Curriculum Changes

• Increased FAER Funding

• Spendable Account Philosophy

• Teaching Rule Lobbying

• NIH Funding Lobbying

• Practice Management

ASA Initiatives

• Governance ChangesTask Force on Graduate Medical Education created in

2001Position on ASA Board of Directors selected by SAACCommittee on Academic Anesthesiology

Changes in committee’s composition

Academic Anesthesiology Committee Changes

The committee should be made up of ASA members, appointed by the President (after consultation with the President of each of the following organizations), one of each being a member from the: American Board of Anesthesiology, Association of Anesthesiology Program Directors, Association of University Anesthesiologists, Foundation for Anesthesia Education and Research, Residency Review Committee for Anesthesiology, Society of Academic Anesthesiology Chairs and Society for Education in Anesthesia, in addition to four adjunct members, one who shall be a resident or fellow . The Chairs of the Committees on Research and Residents and Medical Students and the Vice- President for Scientific Affairs shall serve as members of this committee as ex officio members.

ASA Initiatives

• Governance Changes

• Curriculum Changes

ASA Initiatives

• Governance Changes

• Curriculum Changes

• Increased FAER Funding

• Spendable Account Philosophy

FAER Research Grant Dollars Awarded

How Is Increased FAER Funding Accomplished?

• Change in foundation funding• ASA’s contribution to FAER is to increase from

$1,050,000 to $1,500,000 in 2006 budget• Spendable Account Policy - Report 435-5.1• FAER has adopted a similar policy – see Report

135-2.2

Foundation Funding Changes

ASA’s budgetary process for funding the Foundations will be based on the following: – i. The governance of the Foundations should never be independent from ASA

based on the integral relationship of the Foundations’ purposes to ASA’s purpose.

– ii. Financial independence of the Foundations is not a primary goal of ASA or the Foundations.

– iii. When ASA budgetary considerations allow, ASA will provide the Foundations with the funding necessary to meet the Foundations’ operational needs. The amount of the funding will be an ASA budgeted line item.

– xi. Should ASA funding to one or more of the Foundations fall below the Foundation’s operating expenses on a given year, the Foundation is expected to utilize unrestricted endowment reserves to maintain services and programs.

How Is Increased FAER Funding Accomplished?

• Change in foundation funding• ASA’s contribution to FAER will increase from

$1,050,000 to $1,500,000 in 2006 budget• Spendable Account Policy - Report 435-5.1• FAER has adopted a similar policy – see Report

135-2.2

Spendable Account Language

At its March meeting, the Section on Fiscal Affairs will evaluate ASA’s investment performance and financial situation. The Section will then recommend the percent of the Combined Restricted and Unrestricted Reserves to be used as the following year’s budget as income. This recommendation will be forwarded to the Budget Committee for further consideration.

ASA Initiatives

• Governance Changes

• Curriculum Changes

• Increased FAER Funding

• Spendable Account Philosophy

• Teaching Rule Lobbying

Payment of Physicians in Teaching Settings

Anesthesiologists achieved a breakthrough, long-promised by HCFA, regarding the Medicare rules for payment of teaching physicians. Under a proposed rule issued in February, 1989, HCFA would change the current rules so that full reasonable charge reimbursement would always be recognized when there is one attending physician and two residents. The proposal would also recognize an attending relationship when there is one resident and one CRNA. Final regulations are on an "active track" at HCFA, with publication expected in a few months.

Federal Register Text

• 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, the critical portions of the teaching anesthesia service and the critical portions of the teaching surgeon service are not the same.

Federal Register Text

• The ASA believes that inadequate payment levels have contributed to the loss of teaching anesthesiologists and an inability to recruit new faculty.

• We are requesting comments on a teaching physician policy for anesthesiologists that could build on the policy announced in the November 7, 2003 PFS final rule, but provide the appropriate revisions that would allow it to be more flexible for teaching anesthesia programs.

• We would also 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.

Why Its Hard to ChangeA Personal Opinion

• Budget Constraints

• AANA Opposition

“All of Medicine” Problem Medicare Sustainable Growth Rate

The statute specifies a formula to calculate the SGR based on the estimate of the change in each of four factors. The four factors for calculating the SGR are as follows:

• The estimated percentage change in fees for physicians’ services.

• The estimated change in the average number of Medicare fee-for-service beneficiaries.

• The estimated 10-year average annual growth in real gross domestic product (GDP) per capita.

• The estimated change in expenditures due to changes in law or regulations.

Medicare Physician Payments

$0

$20

$40

$60

$80

$100

$120

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Source: 2004 Medicare Trustees Report

CO

NG

RE

SS

ION

AL

FO

RM

UL

A O

VE

RR

IDE

CO

NG

RE

SS

ION

AL

FO

RM

UL

A O

VE

RR

IDE

CO

NG

RE

SS

ION

AL

FO

RM

UL

A O

VE

RR

IDE

Parity Increases incentives to teach anesthesiologists and discourages nurse anesthesia education, by providing anesthesiologists twice the reimbursement for cases involving medical residents than for cases involving student nurse anesthetists. Further, nurse anesthetists and anesthesiologists provide the same level of patient quality outcomes (Pine study). Medicare already disadvantages nurse anesthesia educational programs by denying nurse anesthesia students and clinical practice sites access to Graduate Medical Education funding, which Medicare provides qualifying medical residents and teaching hospitals by statue. Despite this funding disparity, from 1999-2004 the number of nurse anesthesia educational program graduates grew by 77 percent while the number of graduates from anesthesia residency programs grew by 47 percent. In fact, 12 CRNAs can be educated for the same cost of training one anesthesiologist.

Why Its Hard to Change

Budget ConstraintsAANA Opposition

• Are We United?

Current Status of Teaching Rule

• 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.

Current Status of Teaching Rule

• 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.

AANA Lobbying Material

• Despite this funding disparity, from 1999-2004 the number of nurse anesthesia educational program graduates grew by 77 percent while the number of graduates from anesthesia residency programs grew by 47 percent.

• In fact, 12 CRNAs can be educated for the same cost of training one anesthesiologist.

Current Status of Teaching Rule

• 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 forward with any proposal.

ASA Initiatives

• Governance Changes

• Curriculum Changes

• Increased FAER Funding

• Spendable Account Philosophy

• Teaching Rule Lobbying

• NIH Funding Lobbying

Increased Anesthesiology NIH Funding

• House Labor-HHS Appropriations Bill for 2006 (H.R. 3010)• Passed House on June 24, 2005 • H. Report 109-143 at p. 80 – ASA language on

“Anesthesiology Research” thanks to Rep. David Weldon, MD (R-FL) and the Committee

• "Anesthesiology research - The Committee urges NIGMS to continue to support and enhance research opportunities focused on [1] discovering the mechanisms of anesthesia, [2] perfecting agents for regional and general anesthesia, [3] improving the safety of anesthesia, [4] monitoring and protection of specific organs of patients under anesthesia, and [5] optimizing post-surgery prognosis…

• “The Committee encourages NIGMS to continue to work with other appropriate Institutes to promote improvements in pain research.

• “The Committee believes that NIGMS should strongly support training, innovation and scientific inquiry in these crucial areas of medical research."

Increased Anesthesiology NIH Funding

ASA Initiatives

• Governance Changes

• Curriculum Changes

• Increased FAER Funding

• Spendable Account Philosophy

• Teaching Rule Lobbying

• NIH Funding Lobbying

• Practice Management

Practice Management Brochure

GuidepostsAids to Navigation

Guideposts

• Warner’s 2005 Rovenstine Lecture• Task Force on Future Paradigms of Anesthesia

Practice – October ASA Newsletter

• Schwinn and Balser Article – “Anesthesiology Physician Scientists in Academic Medicine: A Wake-up Call”

Warner’s Rovenstine Lecture

“We must produce new anesthesiologists who are better trained than we have been to pounce on opportunities that will allow our specialty to extend tentacles into all facets of health care.”

“We must hold our future anesthesiologists to higher standards that we have experienced, because we sadly have not as a specialty uniformly pushed ourselves to those higher standards.”

ASA Task Force on Future Paradigms of Anesthesia Practice

“About 15-20 anesthesia programs are now ready to train anesthesiologists of the future.”

“We must act immediately to create the intellectual environment that will actualize the profession’s full and diverse potential by 2025 because change takes time. In some respects, we are already behind, but we have opportunities that can be implemented in the next two to four years.”

Schwinn and Balser Article

“…it should be clear that solid clinical subspecialty training of a much larger number our residency graduates, with compulsory research training at the fellowship level, would have a profoundly positive impact on the future “product” of our training programs,…”

“As such, we suggest that the number of ACGME-accredited clinical fellowships should be increased to include all the legitimate sub-disciplines in anesthesiology, and lengthened and redesigned to encourage deep engagement in research activity.”

New Canal Light