1. The Impact of Legislation on Anesthesia Practice Is Political Activism Optional? Anne T. Lunney, M.D. University of North Carolina

2. UNC / Lunney Considerations of the Average Resident As we transition from trainee to consultant we will consider many variables when considering our first position As we transition from trainee to consultant we will consider many variables when considering our first position Geography Geography Hospital and its milieu Hospital and its milieu Contracts Contracts Partnership tract Partnership tract

3. UNC / Lunney Also Important to Consider… Payer mixnow, and in the future Payer mixnow, and in the future Relationship with CRNA’s and AA’s Relationship with CRNA’s and AA’s Liability environment within the State Liability environment within the State State legislation which supports or protects practice and/or reimbursement State legislation which supports or protects practice and/or reimbursement

4. UNC / Lunney All Are Influenced by Legislation Payer mix Payer mix Medicare and Medicaid reimbursement Medicare and Medicaid reimbursement Relationship with CRNA’s and AA’s Relationship with CRNA’s and AA’s CRNA and AA scope of practice and reimbursement CRNA and AA scope of practice and reimbursement Malpractice and liability Malpractice and liability Tort reform Tort reform

5. UNC / Lunney Who is Advocating for Anesthesiologists Anesthesiologist and Anesthesia Residents Anesthesiologist and Anesthesia Residents American Society of Anesthesiologists American Society of Anesthesiologists State anesthesia societies State anesthesia societies National and state ASA PACs National and state ASA PACs The American Medical Association The American Medical Association Legislators Legislators

6. UNC / Lunney ASA Pro-physician, pro-anesthesia, pro-patient safety Pro-physician, pro-anesthesia, pro-patient safety Educate anesthesiologists, legislators, and the general public Educate anesthesiologists, legislators, and the general public Propose legislation and find representatives who will sponsor and support said legislation Propose legislation and find representatives who will sponsor and support said legislation

7. UNC / Lunney Political Action Committee PACs serve the interests of their constituents PACs serve the interests of their constituents Pooling of funds Pooling of funds Collective effort Collective effort Unified voice Unified voice Support specific legislation and legislators at the state and national level Support specific legislation and legislators at the state and national level Lobby Lobby

8. UNC / Lunney The Issue’s Teaching Rule Teaching Rule Reimbursement Parity Reimbursement Parity Sustained growth rate formula Sustained growth rate formula Gubernatorial supervisory opt out Gubernatorial supervisory opt out Rural pass through Rural pass through CRNA scope of practice legislation CRNA scope of practice legislation Tort reform Tort reform

9. UNC / Lunney Teaching Rule 1991 Medicare regulatory change, instituted in 1994 1991 Medicare regulatory change, instituted in 1994 Anesthesiology teaching faculty Medicare reimbursement is decreased by 50% if the teaching faculty is supervising more than one resident when caring for Medicare patients Anesthesiology teaching faculty Medicare reimbursement is decreased by 50% if the teaching faculty is supervising more than one resident when caring for Medicare patients Private insurance companies are starting to reimburse teaching physicians in a similar fashion Private insurance companies are starting to reimburse teaching physicians in a similar fashion Not applied to any other teaching physicians, including surgeons Not applied to any other teaching physicians, including surgeons

10. UNC / Lunney Teaching Rule Since the institution of this Medicare regulation, the number of Anesthesiology residency programs has decreased from approximately 160 to 130 programs Since the institution of this Medicare regulation, the number of Anesthesiology residency programs has decreased from approximately 160 to 130 programs Costs Academic Anesthesiology departments $400,000+ per year Costs Academic Anesthesiology departments $400,000+ per year

11. UNC / Lunney Teaching Rule HB 5246 introduced by House Representatives Shaw and Sessions in May of 2006 HB 5246 introduced by House Representatives Shaw and Sessions in May of 2006 Medicare teaching anesthesiology funding restoration act Medicare teaching anesthesiology funding restoration act Fashioned to reverse the 1991 regulatory change Fashioned to reverse the 1991 regulatory change Similar legislation to follow in the Senate Similar legislation to follow in the Senate

12. UNC / Lunney Reimbursement Parity 1992 – Medicare fee schedule for reimbursement of anesthesiology services 1992 – Medicare fee schedule for reimbursement of anesthesiology services The conversion factor using absolute dollars is paying < 80% of what it was in 1991 The conversion factor using absolute dollars is paying < 80% of what it was in 1991 <40% of what is paid by private insurers <40% of what is paid by private insurers Other specialties reimbursed ~ 80% of what is paid by private insurers Other specialties reimbursed ~ 80% of what is paid by private insurers

13. UNC / Lunney Reimbursement Parity ASA is providing the General Accounting Office with information on the disparity between private insurance reimbursement and Medicare reimbursement ASA is providing the General Accounting Office with information on the disparity between private insurance reimbursement and Medicare reimbursement The evaluation is an undertaking of the ways and means subcommittee and is supported by House Representatives Nancy Johnson and Pete Stark The evaluation is an undertaking of the ways and means subcommittee and is supported by House Representatives Nancy Johnson and Pete Stark

14. UNC / Lunney Medicare Sustained Growth Rate Formula Medicare part B Medicare part B 2007 projected cut of 4.6% 2007 projected cut of 4.6% Projected average annual cut of 5% from the years 2007 to 2012 Projected average annual cut of 5% from the years 2007 to 2012 Cut averted annually with stop-gap measures Cut averted annually with stop-gap measures We are fighting simply to prevent annual cuts, rather than supporting a reimbursement system that is consistent with the cost of delivering care We are fighting simply to prevent annual cuts, rather than supporting a reimbursement system that is consistent with the cost of delivering care

15. UNC / Lunney SGR Also influenced by Drug payment is grouped into the physicians services funding pool Drug payment is grouped into the physicians services funding pool The cost of medication is steadily increasing and thus decreasing the ability to fairly reimburse physicians The cost of medication is steadily increasing and thus decreasing the ability to fairly reimburse physicians The cost of physician services are increased with the institution of any state or national regulatory change The cost of physician services are increased with the institution of any state or national regulatory change

16. UNC / Lunney SGR The Medicare payment advisory commission (medPAC) recommended reimbursement requiring an estimation of changes in input for the coming year, less an adjustment for growth in multifactorial productivity The Medicare payment advisory commission (medPAC) recommended reimbursement requiring an estimation of changes in input for the coming year, less an adjustment for growth in multifactorial productivity The Medicare Economic Index (MEI) is similar to the current payment update formula utilized for hospitals, Nursing homes, and other medicare providers which are based on practice cost increases The Medicare Economic Index (MEI) is similar to the current payment update formula utilized for hospitals, Nursing homes, and other medicare providers which are based on practice cost increases

17. UNC / Lunney SGR HR 3617 HR 3617 Introduced by House Representative Nancy Johnson Introduced by House Representative Nancy Johnson Repeal the SGR formula and replace it with a MEI reimbursement adjustment mechanism Repeal the SGR formula and replace it with a MEI reimbursement adjustment mechanism Parity with services other than physicians that are reimbursed by Medicare Parity with services other than physicians that are reimbursed by Medicare

18. UNC / Lunney Supervision Opt Out 2001 - ruling on Medicare and Medicaid regarding anesthesia conditions of participation for critical access hospitals and ambulatory surgical centers 2001 - ruling on Medicare and Medicaid regarding anesthesia conditions of participation for critical access hospitals and ambulatory surgical centers Governors can opt out of the national standard of supervision of CRNA’s Governors can opt out of the national standard of supervision of CRNA’s Outcome studies on unsupervised CRNA’s Outcome studies on unsupervised CRNA’s 25 more deaths per 10,000 medicare patients 25 more deaths per 10,000 medicare patients Limitation of surgery in rural areas is not limited by Anesthesia limitations Limitation of surgery in rural areas is not limited by Anesthesia limitations

19. UNC / Lunney Supervision Opt Out Reimbursement is the same under Medicare for Reimbursement is the same under Medicare for Anesthesiologist (100% to MD) Anesthesiologist (100% to MD) Anesthesiologist supervising a CRNA (50%CRNA:50%MD) Anesthesiologist supervising a CRNA (50%CRNA:50%MD) Surgeon supervising a CRNA (100%CRNA) Surgeon supervising a CRNA (100%CRNA) CRNA practicing without supervision (100%CRNA) CRNA practicing without supervision (100%CRNA) Financial incentive Financial incentive

20. UNC / Lunney Rural Pass Through Medicare part B Medicare part B Reimbursement for Anesthesiologists Reimbursement for Anesthesiologists Rural hospitals with surgical caseloads Rural hospitals with surgical caseloads < 800 per annum reimbursed via Medicare part A < 800 per annum reimbursed via Medicare part A Rural pass through to CRNAs and AAs only Rural pass through to CRNAs and AAs only Extend exception to include Anesthesiologists! Extend exception to include Anesthesiologists!

21. UNC / Lunney Scope of Practice – CRNA’s CRNA’s and AA’s are not trained to make medical judgments CRNA’s and AA’s are not trained to make medical judgments Direct and immediate supervision or the existence of a protocol/collaborative arrangement with a physician Direct and immediate supervision or the existence of a protocol/collaborative arrangement with a physician Credentialing of CRNA’s should take practice environment into account and they should not be credentialed to perform medical diagnostic assessment, indications, contraindications and treatment in response to complications that require medical skill and judgement Credentialing of CRNA’s should take practice environment into account and they should not be credentialed to perform medical diagnostic assessment, indications, contraindications and treatment in response to complications that require medical skill and judgement

22. UNC / Lunney Tort Reform Physicians leaving or curtailing their practice Physicians leaving or curtailing their practice Defensive medicine – 60 billion per year Defensive medicine – 60 billion per year Medical liability increase 750% since 1975 Medical liability increase 750% since 1975 Compared with 245% increase in California Compared with 245% increase in California 1975 California Medical Injury Compensation Reform Act (MICRA) 1975 California Medical Injury Compensation Reform Act (MICRA)

23. UNC / Lunney Tort Reform MICRA Recover unlimited economic damages Recover unlimited economic damages $250,000 limit on noneconomic damages $250,000 limit on noneconomic damages $250,000 limit on punitive damages or 2X economic damages – clear and convincing evidence of malicious intent $250,000 limit on punitive damages or 2X economic damages – clear and convincing evidence of malicious intent Allocation of damages of multiple defendants proportional to fault Allocation of damages of multiple defendants proportional to fault Limits on contingency fees that may be charged to plaintiffs Limits on contingency fees that may be charged to plaintiffs

24. UNC / Lunney Tort Reform S. 22 S. 22 Medical care access protection act of 2006 Medical care access protection act of 2006 Comprehensive medical liability reform modeled on MICRA Comprehensive medical liability reform modeled on MICRA S. 23 S. 23 Healthy mothers and healthy babies access to care act Healthy mothers and healthy babies access to care act Targeted medical liability reform Targeted medical liability reform

25. UNC / Lunney What can you do? Understand the issues that affect your practice at both the state and national level Understand the issues that affect your practice at both the state and national level The ASA and the ASAPAC is an excellent source of updated information The ASA and the ASAPAC is an excellent source of updated information The ASA website has all of the key issues from the May 2006 meeting outlined The ASA website has all of the key issues from the May 2006 meeting outlined Start small rather than not at all Start small rather than not at all Pick a single issue that you feels strongly about Pick a single issue that you feels strongly about

26. UNC / Lunney What can you do? Speak out Speak out Specific legislation that is currently active and needs support now is HR 5246 (rectifying the teaching rule), and S. 22 and S 23 (tort reform) Specific legislation that is currently active and needs support now is HR 5246 (rectifying the teaching rule), and S. 22 and S 23 (tort reform) Write to your legislators – Lobby Write to your legislators – Lobby Express your feelings and share your knowledge about a specific piece of legislation you would like them to support Express your feelings and share your knowledge about a specific piece of legislation you would like them to support Thank them for legislation they have supported Thank them for legislation they have supported

27. UNC / Lunney What can you do? Join state and national anesthesiology and medical associations Join state and national anesthesiology and medical associations Residents can join the national and state PACs for as little as $25 Residents can join the national and state PACs for as little as $25 Remember if all residents gave $25, it would really add up!!!!!!!! Remember if all residents gave $25, it would really add up!!!!!!!!

28. UNC / Lunney Remember If the collective Anesthesiology voice is not heard, Decisions will be made without your input If the collective Anesthesiology voice is not heard, Decisions will be made without your input And, decisions will be made with the input of the opposition And, decisions will be made with the input of the opposition Insurance companies Insurance companies AANA AANA The Center for Medicare and Medicaid Services (CMS) The Center for Medicare and Medicaid Services (CMS)

29. UNC / Lunney Thank You Be educated Be educated Be active Be active Or….support the organizations who are working on your behalf Or….support the organizations who are working on your behalf OUR FUTURE IS IN OUR HANDS OUR FUTURE IS IN OUR HANDS