Gasline Newsletter August 2008

Volume 10, No. 3

2008 Fall Hawaiian Seminar

Don't forget to sign up for the 2008 CSA Hawaiian Seminar at the Mauna Lani Resort, October 27-31, 2008. This year's featured speakers are Manuel Pardo, Jr., M.D., William Camann, M.D., Michael A. Gropper, M.D., Ph.D., Steven Hall, M.D., and Francis V. Salinas, M.D. The topics for the meeting include:

Transfusion Issues
Mechanical Ventilation
Obstetric Anesthesia
Regional Anesthesia
Pediatric Anesthesia
Trends in Anesthesia Training & Certification
       … and much more!

Subspecialty Certification in Pediatric Anesthesiology

A current “hot button” issue receiving attention at the national level of organized anesthesiology is a proposal submitted by the Society for Pediatric Anesthesia (SPA) calling for subspecialty certification in pediatric anesthesiology. This request was initially directed to the American Board of Anesthesiology, which then forwarded it to the ASA requesting comment. The issue was floated at the February ASA Board Meeting where it received a reception almost as chilly as the Chicago weather. After that defeat, the proposal resurfaced as a request for certification in “Advanced Pediatric Anesthesiology” in an attempt to placate those who particularly dislike the concept of sub-certification in a discipline integral to the practice of anesthesiology.

The proponents claim that the certification is necessary to provide confirmation of the skills acquired in the accredited pediatric anesthesiology fellowship programs; opponents feel that it would ultimately lead to the “Balkanization” of anesthesiology, as well as the creation of “second-class” ABA diplomates who perform pediatric anesthesiology fully competently, although without the benefit of fellowship training.

The revised proposal failed to win support at the August ASA Board meeting this month, but the issue is not yet dead. Debate at this year's ASA Annual Meeting is likely to be heated, and SPA seems determined to continue in its quest.

Billing for Non-contracted Services

The battle in Sacramento over attempts to limit billing for non-contracted services (balance billing) continues to rage on both the regulatory and legislative fronts.

On August 1, California Department of Managed Health Care (DMHC) Director Cindy Ehnes announced that the agency had finalized new regulations restricting the practice of balance billing for care administered to HMO patients in emergency settings. The regulations deem the custom an “unfair billing practice,” thus allowing DMHC enforcement actions against those providers who seek payment from the patients themselves when the HMO has refused to pay for their care. The regulations do nothing to obligate the HMOs to either maintain adequate networks or pay non-contracted physicians fairly.

The proposed regulations must now go to the Office of Administrative Law (OAL), which has 30 business days to review them. The CSA and the California Medical Association (CMA) believe strongly that DMHC lacks the authority to promulgate or enforce the regulations. If the regulation is approved by the OAL, CMA and CSA plan to challenge the DMHC in court. CMA has already assembled an outside legal team and is in the process of raising funds for a legal battle. As a specialty that would be highly impacted by the proposed regulations, we must be prepared to contribute to the cause.

On the legislative side of the same issue, SB 981 (Perata), which would also prevent physicians from billing HMO patients directly, is still alive. The current perception in Sacramento is that this issue will not simply go away, and that anesthesiologists will be far better served by being seen as part of a solution to the problem rather than as simply opposed to any limitations whatsoever. As a result, CSA is considering sponsoring its own legislation.

In order to be successful, any CSA proposal cannot be viewed as overtly self-serving, and must have the appearance of being fair to anesthesiologists, insurers and patients. CSA Legal Counsel Phillip Goldberg has prepared draft legislation calling for baseball-style arbitration of fees between physicians and insurers in return for an agreement not to bill the patients directly. The proposal deals only with payment for emergency services to HMO patients by non-contracted physicians. CSA has no immediate plans to introduce this legislation, but will continue to follow the issue closely.

Chiropractic Manipulation Under Anesthesia

CSA also anticipates a battle in Sacramento over chiropractic manipulation under anesthesia (MUA). CSA is currently awaiting the issuance of draft regulations by the California Board of Chiropractic Examiners regarding the procedure, but expects a significant clash with the Board over the issue of whether or not MUA is in fact within the chiropractic scope of practice.

Chiropractic practice by definition precludes the use of medications. Chiropractors who perform MUA claim that anesthesia is not an integral component of the technique, thereby keeping it within their scope of practice. CSA strongly disagrees with this logic.

In preparation for the anticipated legal wrangling, CSA Legal Counsel David Willett, CSA CEO Barbara Baldwin and I sent letters to the ASA requesting financial assistance from the national society to CSA for waging this fight on behalf of all of organized anesthesiology. Our request that ASA match CSA's legal expenditures on a dollar-for-dollar basis, up to a total of $15,000, was approved by the ASA Executive Committee.

Clearly, ASA leadership agreed with our position that, although the fight is going to occur in California, it is not without national implications.

Ultrasound for Regional Anesthesia, December 6, 2008—Save the Date!

On December 6, 2008, CSA will have a workshop in Ultrasound for Regional Anesthesia in the San Francisco Bay Area. Save the date and watch for more information!

Paul Thomas, M.D., CSA Past President

Dr. Paul Thomas, CSA President in 1983-1984, passed away on August 4, 2008. Dr. Thomas was a great advocate for the anesthesiology profession and served this organization for many years, culminating in his presidency in 1983. We mourn his passing but are grateful for the legacy he left CSA and the profession.

Michael W. Champeau, MD