Gasline Newsletter August 2009

Volume 11, No. 4

National Health Care Reform

As I write this, we are in the middle of the Congressional recess. President Obama has been holding controlled town hall meetings to get his message out while Congressional Representatives are canceling theirs since they fear the type of reception they will receive. In the news there is talk that the so-called “public plan” may be jettisoned from the legislation upon the return of Congress and that there has been a softening of the White House’s and progressive Democrats’ positions on this issue. However, the situation remains fluid with changes occurring almost daily.

A number of you have asked what the CSA and ASA are doing about what is happening in Washington, D.C., and more specifically about H.R. 3200, the bill on health care reform currently being heard in committee in the House of Representatives.

As many of you are aware, the AMA has endorsed this bill. On behalf of the ASA, President Roger Moore has opposed this move by the AMA, as have a number of other specialty societies. The ASA is not currently working with any specialty society consortium that may be forming because the issues specific to anesthesiologists may not be pushed as aggressively as we might like. This could change in the future. In the meantime, the ASA is urgently requesting that we contact our Congressional Representatives and let them know what we think. The ASA has not taken a specific position on the type of health care delivery model that should be pursued, but is forcefully pursuing an agenda of advocating for the de-coupling of the Medicare payment system that currently exists from the so-called public plan. The ASA is also advocating for a public plan that is voluntary and has payment rates that are negotiable. In addition, the ASA is continuing its work to obtain an increase in Medicare rates for anesthesiologists from their current level of 33% of commercial. This was discussed in the message of August 7, 2009, from ASA President Dr. Roger Moore, where he outlined what ASA members could do to assist with advocacy. This letter was subsequently copied to the CSA membership along with a message urging continued advocacy efforts with their Congressional representatives in August.

The link to the ASA with talking points and instructions for doing this is:
Click on the “CALL NOW” zip code link. Once you have made your calls, please fill out the form on that page so the ASA knows you have made contact.

On the CSA level, we are mobilizing members in key congressional districts to make contact with the so-called “Blue Dog Democrats.” If any of you have a relationship with these individuals, please contact them as well. They are:

Joe Baca (D – 43rd) 202-225-6161 Health LA: Brenda D. Villanueva
Dennis Cardoza (D – 18th) 202-225-6131 Health LA: Nora Todd
Jim Costa (D – 20th) 202-225-3341 Health LA: Jacqlyn Schneider
Jane Harman (D – 36th) 202-225-8220 Health LA: Linda Shim
Loretta Sanchez (D – 47th) 202-225-2965 Health LA: Jessica Fernandez
Adam Schiff (D – 29th) 202-225-4176 Health LA: Aaron Baird
Mike Thompson (D – 1st) 202-225-3311 Health LA: Travis Robey
As President of the CSA, I sent a letter in mid-July to each and every congressional representative from California outlining our national society’s position. A copy of the letter is attached herebelow. You should use the information outlined here, on the ASA Web Site, and in the letter as your talking points when you call or e-mail your representatives.

In addition, I urge you to make contributions to the ASAPAC or GASPAC, the political action arms of the ASA and CSA respectively.

The Governor’s Opt-Out from the CMS Requirement for Physician Supervision of CRNAs

The second issue over the past month has been the Governor’s decision to send a letter to CMS to opt out of physician supervision of CRNAs in California. This letter was sent in June, but the effective date was July17, 2009. CMS subsequently posted the information that California had “opted out” on its Web site on July 21, 2009. The decision by the Governor was made in great secrecy, behind closed doors, and without attention to proper CMS process which requires that opting out be consistent with state law, that the Medical and Nursing Boards be consulted, and that the Governor attest that the opt-out is in the best interests of the citizens of the state. It appears that the secrecy was an intentional effort to keep interested stakeholders from attempting to influence a decision that the Governor and his health policy makers had already made.

This action was taken in blatant disregard of state law that requires physician supervision of nurse anesthesia, and this was reiterated by the Medical Board of California, who advised, “a nurse anesthetist is required to have physician (dentist, podiatrist) supervision.” Federal regulations stipulate that a “Governor must attest that he or she has consulted with State Boards of Medicine and Nursing about issues related to access to and quality of anesthesia in the State.” The letter to CMS did not include that required specificity, nor did it attest that the opt-out would be in the best interests of the citizens of California, another stipulation. Therefore, a letter from the CSA was sent to the Governor urging that the Governor’s letter to CMS be withdrawn because he ignored state law, the opinion in the letter of the California Medical Board (MBC), and the requisite required specificity of the federal regulation.

At this time we are awaiting a response from the Governor’s office to the letter and other overtures, having met with multiple individuals in Sacramento with the potential to influence the Governor on this issue. All avenues, including legal means to have this action withdrawn or overturned, will be explored and implemented. The CMA and ASA are assisting the CSA in its efforts to have the opt-out reversed.

Join ASA President Roger Moore, M.D., for a Health Care Tele-Town Hall on Sept. 3

Mark your calendar for the ASA Health Care Tele-Town Hall: Thursday, Sept. 3 at 7 p.m. EDT. The conference call, open to all ASA members, is designed to provide a last-minute health care reform update before the House and Senate reconvene from the August Congressional Recess.

ASA members are encouraged to call in and listen as ASA President Roger A. Moore, M.D., provides a status report of current health care reform efforts and offers a forecast for what to expect once Congress reconvenes. Participants can also take part in a question and answer session after the presentation.

Please use the following information to join the call:

Toll-free dial-in: 800-362-3139
Conference ID: 26747634
Please contact Sarah Byun in the ASA Washington office at 202-289-2222, or, for more information.

CSA Fall Hawaiian Seminar

Don’t miss the CSA’s Fall Hawaiian Seminar, October 26-30, 2009, on the Garden Isle of Kauai. CSA is offering a world-class scientific program in one of the most gorgeous locations on earth. Bring the family and earn CME in the morning, and play in paradise in the afternoon. Topics will include:

What We Can Learn From Closed Claims in Obstetric Anesthesia
Echocardiography for the Non-Cardiac Anesthesiologist
Sugammadex: Do We Need It: Will We Get It?
Depth of Anesthesia and Awareness
Prevention and Management of Pediatric Cardiac Arrest
New Options to Optimize Labor and Cesarean Delivery Analgesia
How to Avoid a Lawsuit
Book your sleeping room as soon as possible on the Hyatt’s online CSA registration site at The Mountain View rooms are going fast!

CSA Sends Final Dues Statement

Final dues reminders were mailed at the beginning of August. Please support the profession as changes in health care have a direct impact on patient safety and your livelihood. As you prepare to renew your membership, remember that your CSA/ASA membership entitled you to registration for the ASA Annual Meeting free of charge, and a substantial discount on CSA-sponsored destination CME programs.

If you have any questions, simply call the CSA office or simply renew online ( Many group practices have set up a “Group Billing Account” for their members. In this way, one check is written for everyone, saving time, administrative hassle and mailing expense. If your practice does not already have a Group Billing account, ask your Group Administrator to contact Tom-Philip Baclagan at 650-345-3020 for more information.

Linda B. Hertzberg, M.D.

Letter sent to all congressional representatives from Dr. Hertzberg:

July 16, 2009

The Honorable George Radanovich 
U.S. House of Representatives 
2367 Rayburn House Office Building 
Washington, DC 20515-0001

Dear Congressman Radanovich:

I am writing this letter requesting that you vote against H.R. 3200, “America’s Affordable Health Choices Act”, as currently written, and more particularly the provision that creates a new government-sponsored insurance option tied to Medicare payment rates. As you may well be aware, Medicare pays anesthesiologists only 33% of the average amounts paid by commercial insurance carriers. This contrasts sharply from the 78% of commercial rates Medicare pays the rest of medicine. Such low reimbursements are not sustainable as they do not reflect the true cost of providing care. If a bill such as this becomes law, it will create a critical shortage of anesthesia providers, which will restrict access to safe anesthesia, care for surgery, pain management, and other anesthesia services.

Anesthesiologists, as well as other hospital based physicians, are almost always required by the hospital where they work to treat all patients who present for care regardless of the type of insurance. This differs markedly from other physicians who decide which insurances to accept and may opt out of the Medicare program entirely or simply refuse to admit new Medicare patients to their practice. This requirement to “treat all patients” has been exploited by Medicare to reduce payment to hospital based physicians below the level that would otherwise be required to retain sufficient providers to treat Medicare patients. The insufficient Medicare funding has not created a critical shortage of anesthesiologists due to the fact that commercial payers make up the reimbursement shortfall. Extending Medicare rates to the public plan will eliminate this additional funding, and drive qualified anesthesiologists out of the profession. In addition it may severely reduce the number of new graduates who choose anesthesiology as a profession.

The insufficient reimbursement by Medicare is not a new issue. In 1992, a separate conversion factor for anesthesia services was implemented and anesthesia payments were decreased 29%. Although Medicare has reviewed rates several times since 1992, this historical underpayment for anesthesia services has continued. In a 2002 survey of health plans sponsored by the Medicare Payment Advisory Commission, researchers estimated that Medicare payments for anesthesia services were about 61% lower than private insurance payments. In July 2007, the Government Accountability Office (GAO) issued a report that found Medicare payments to anesthesiologists had declined to a level 67% lower than average private insurance payments (GAO-07-463). In its July 27, 2007 letter to Pete Stark, the GAO stated: “… [T]he difference between Medicare and private payments for anesthesia services is larger than the difference in payments for other physician services, raising the concern that Medicare payment levels could affect where anesthesia practitioners locate and more generally whether interest in anesthesiology as a profession is also affected. [Emphasis added]”.

The California Society of Anesthesiologists (CSA) and the American Society of Anesthesiologists (ASA) firmly believe that payments for anesthesia services under the public plan option must be unlinked from Medicare payment rates. We request that anesthesia rates under the “public health insurance plan” be fair and commensurate with those rates of other physicians relative to commercial rates, detailed above. Accordingly, given Medicare’s historical underpayment for anesthesia services, I respectfully request that you work to amend or vote against H.R. 3200 and any other bill that ties payment for anesthesia services to Medicare rates.

The future of the medical specialty of anesthesiology depends on the outcome of this important issue.

Thank you for your efforts and attention.

Respectfully Yours,

Linda B. Hertzberg, M.D. 
President, California Society of Anesthesiologists