The "Hunger Games" of Payment: News From the CSA House of Delegates

  • Sibert, Karen, MD, FASA
| Jun 08, 2015

“This is what I call the ‘Hunger Games’ of physician payment,” Marc Leib, MD, JD, told his audience of CSA officers, district directors, and delegates at the annual House of Delegates meeting in Los Angeles on June 6.  “In order for you to win, someone else has to lose.”

Dr. Leib was talking about HR 2, the federal bill passed in April that repealed the Sustainable Growth Rate (SGR) formula. The SGR threatened to impose a massive 21% Medicare pay cut, so its repeal was greeted with joy by many physicians including AMA leaders. “It seemed as if physicians everywhere were singing the Hallelujah Chorus,” said Dr. Leib, who chairs the ASA Committee on Economics. But the ASA had serious reservations, and was the only major medical society that did not sign a letter in support of the bill.

Even with the SGR gone, Dr. Leib explained, 2% sequestration cuts to Medicare payment remain in effect until 2024. Under HR 2, physicians will receive only a 0.5% pay increase each year through 2019, the year that CMS will institute the new “Merit-Based Incentive Payment System” (MIPS) and put physicians at risk for performance-based pay cuts or bonuses. Fee increases aren’t likely to keep up with inflation, he said. “This is very scary!”

Congratulations to new CSA President James Moore, MD

Dr. Leib’s talk was part of the weekend education and governance meeting that brought together CSA leaders from all over California. They elected four new officers:

  • President, James Moore, MD
  • President-Elect, Mark Zakowski, MD
  • Chair, Legislative and Practice Affairs Division (LPAD), Jeffrey Poage, MD
  • Vice-Chair for Practice Affairs, LPAD, John Hsieh, MD.

Other officers will continue in their present posts for the 2015-16 term:

  • Speaker of the House, Christine Doyle, MD
  • Vice-Speaker, Edward Mariano, MD, MAS
  • Secretary, Karen Sibert, MD
  • Assistant Secretary, Rima Matevosian, MD
  • Treasurer and Chief Financial Officer, William Feaster, MD, MBA
  • Assistant Treasurer, Judi Turner, MD, PhD
  • Vice-Chair for Legislative Affairs, LPAD, Keith Chamberlin, MD, MBA
  • Chair, Education and Programs Division (EPD), Samuel Wald, MD, MBA
  • ASA Director from California, Michael Champeau, MD
  • ASA Alternate Director from California, Linda Hertzberg, MD.

The House of Delegates enjoyed its first opportunity to meet David Butler, who will take over as the CSA’s Executive Director on July 1. Since the resignation of the previous Executive Director last summer, the CSA office has benefited from the expertise of interim executive Julie Freeman. Over the winter, the CSA Board of Directors investigated all options and determined that the organization would be best served into the future by engaging an association management firm rather than continuing to fund its own office and staff. After an extensive RFP process, the Board decided to sign a contract with Advocacy & Management Group (AMG) of Sacramento. Mr. Butler, while an employee of AMG, will function as the CSA’s Executive Director, heading up the team of AMG staff members who will support the CSA’s membership, office administration, communications, educational programs, and other functions.

Update from ASA President-Elect Daniel Cole, MD

“I’m here to tell you the facts as I see them,” said Daniel Cole, MD, the ASA’s President-Elect, giving the CSA an update on ASA affairs at the national level. “Not everything is rosy.”

He agreed with Dr. Leib’s assessment of the new problems that the SGR repeal will cause. “Sometimes the solution is as bad or even worse than the problem,” Dr. Cole said, calling HR 2 a “value-destroyer” that will turn payment upside down. Pay bonuses can’t exceed pay cuts since the program must remain budget neutral. “You can in theory move the entire quality curve to the right,” Dr. Cole explained, but physicians at the lower end of quality metrics would still suffer a penalty. “This is the wrong way to improve quality!”

In other developments, more and more anesthesiologists today are employed by hospitals or health care organizations (HCO)s. Your HCO may end up merging with another or being acquired, Dr. Cole said, and new “mega-groups” of 1000 or more anesthesiologists are becoming more common. The ASA’s challenge is to speak for all anesthesiologists with one voice.

“The organizations that are going to thrive in the future are integrated care organizations,” he predicted. Those that are delivering fragmented care and working in “silos” won’t survive. There is already great pressure on hospitals and HCOs to reduce costs. “We’re going to be right in the middle of that argument,” said Dr. Cole, and it’s critically important to have a seat at the table. “If the business model falls apart, all of our other missions fall apart.”

“Our value proposition has to change,” he said. “We can’t be just induction-to-emergence physicians.” The Perioperative Surgical Home (PSH) is one delivery system that can help anesthesiologists improve their strategic position, and it aligns well with alternative payment models (APMs), he said.

“The government wants delivery system reform to move payment toward APMs, and minimize fee-for-service payments that are not linked to quality or value,” Dr. Cole said. “I think traditional fee-for-service is dying. Everything will be linked to quality metrics.”

“We cannot lose this battle!”

Dr. Cole identified other serious challenges ahead. Proposed changes to the VA Nursing Handbook would designate all advanced practice nurses in the VA system as “Licensed Independent Practitioners”, and remove physicians from veterans’ care. Dr. Cole said that after the handbook is issued, there will be a period of time for public comment and we will need to ramp up anesthesiologist efforts in opposition. “We cannot lose this battle!” he declared.

Disruptive technology such as machine-controlled moderate sedation raises a new question, Dr. Cole said. “Do we resist disruptive technology or exploit it?”

Finally, Dr. Cole pointed out that many policymakers and members of the public are still unaware that anesthesiologists are physicians. “This won’t be cured by one Superbowl commercial,” he noted. “But when they understand that we are physicians, we have a strong message. The public wants a physician there in case of an emergency. When your life is on the line, you want a physician there to make decisions.”

The ASA has 53,000 members, Dr. Cole said. “If all those physicians were active in advocacy, we would solve that problem!”

ICD-10: Is your practice ready?

Dr. Leib’s second talk on Sunday morning, June 7, focused on the upcoming implementation of ICD-10. “As of October 1,”, he declared, “if you submit a claim without ICD-10 codes, you will not get paid!”

ICD-10 is not a new system, Dr. Leib explained. It was first published in 1990, contains some 12,500 codes, and is used by every other country in the world except the US. The version that we will use in the US is known as ICD-10-CM and has a startling 69,000 diagnostic codes. Dr. Leib recommended a CMS website as an information resource for physicians.

The good news, however, is that only a very small percentage of the codes will be used by most physicians, Dr. Leib said. Some 25,000 of the codes do nothing more than distinguish right from left, and 17,000 concern orthopedic fractures. “All these codes become much less scary when you realize that most of them we will never use.”

Dr. Leib recommended that anesthesiologists simply document what they know about the patient’s diagnosis and procedure, and the coder will find the code. However, he suggested that anesthesiology groups start having their coders use the new codes now for practice, even just for one case a day. “By the time you get to October 1, their productivity will get better,” he said. “If you don’t do this now, your cash flow will come to a screeching halt!”

Meeting highlights

The House of Delegates, under the leadership of Speaker Christine Doyle, MD, conducted its official business on June 7.

The first order of business was the presentation of the Distinguished Service Award to William Barnaby, Esq., who served as the CSA’s chief lobbyist and voice in Sacramento for more than 30 years. Larry Sullivan, MD, a CSA past president, introduced Mr. Barnaby, calling him a “paragon of ethical behavior and professionalism”, and pointing out how well his reputation of “political wizardry and integrity” served the CSA. Mr. Barnaby was instrumental in the victory of getting MICRA passed, which limited malpractice payments for pain and suffering, and has kept malpractice insurance costs manageable.

Johnathan Pregler, MD, a CSA past president who chaired this year’s Committee on the Distinguished Service Award, nominated the 2016 candidate, Linda Mason, MD. Dr. Mason served as CSA President in 2004-5, and has been elected to national ASA office, first as Assistant Secretary and now as Secretary. Dr. Mason’s nomination was confirmed by the House, and she will receive the award at next year’s governance meeting.

President Paul Yost, MD, gave farewell remarks before presiding over the induction of Dr. Moore as the next CSA President. Though AB 890, a CSA-supported bill that would have allowed certified anesthesiologist assistants (CAAs) to practice in California, did not progress past the committee stage, Dr. Yost commended Dr. Zakowski and Bryce Docherty, the CSA’s head lobbyist, for outstanding work in getting the bill so far through the legislative process in the first year. He also commended them for leading the CSA’s successful effort in opposing Proposition 46 last fall.

Dr. Yost emphasized how important it is for CSA members to be members of the CMA too. “We’re only 2% of the physician population,” he said. “We don’t have a large footprint.” In order for legislative efforts to succeed, he said, the CSA must build alliances with other physician groups.

The CSA must also continue to work on improving its value proposition to members and to residents, Dr. Yost said. “Residents want a vibrant, growing profession that pays the bills!”

Dr. Moore, in his remarks as President-Elect, reiterated the importance of membership to the CSA’s success. “We need to understand what members really want from their society,” he said. “We need to keep pace with new models of learning.” The CSA must maintain continued communication with members, listen to their misgivings, and show them how CAAs can help to ensure the long-term health of the anesthesiology profession in California, Dr. Moore said.

In his LPAD report, Dr. Zakowski echoed Dr. Moore’s support of CAA practice. He pointed out that no state has ever passed CAA legislation on the first attempt. Dr. Zakowski reminded the House of Delegates that advocacy is in the interests of patient safety. “You have to advocate for yourself in order to take care of your patients the way you want to take care of them,” he said. Talking to legislators may seem hard at first, but it’s not impossible. “I’m an introvert,” Dr. Zakowski declared. “I learned to do it, I learned to love it, and I got pretty good at it. You can too!”

The Reference Committee, chaired by Sydney Thomson, MD, shepherded the House through bylaws revisions and updates. A motion to require CMA membership of all CSA officers was referred for further consideration to a committee of the President’s choice. The question of whether to establish a new category of Educational Membership, similar to the ASA’s Educational Membership, was referred back to the Bylaws Committee for further development.

The following CSA members were named to new three-year terms as delegates to the ASA:  Christine Doyle, MD, John Hsieh, MD, Manuel Pardo, MD, Ronald Pearl, MD, PhD, Mark Singleton, MD, Narendra Trivedi, MD, Judi Turner, MD, PhD, Jeffrey Uppington, MBBS, and Paul Yost, MD.

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