Until very recently, I was grossly unfamiliar with advocacy and legislative affairs like the No Surprises Act, the 33% Problem, and the Stone Memo. But after attending the ASA ADVANCE event in Dallas earlier this year, I feel educated and well-equipped to bring these issues to the attention of my co-residents. Here’s why we as residents should – in fact, must – care about the regulations that could pose a threat to our specialty. By Eric Reilly, DO
In late January I had the privilege of attending ASA ADVANCE (previously ASA Practice Management) in Dallas, Texas. This annual conference brings together anesthesiologists, residents, political activists, strategists, information technologists, employers, and many more to promote strategic solutions which ensure successful performance across all anesthesia practice models. I was particularly moved by the Presidential Address, in which ASA President Dr. Randall Clark showcased the key battles facing current and future anesthesiologists. Here's what I learned.
The No Surprises Act
The No Surprises Act was a section of a bill passed in December 2020 aiming to protect patients from surprise medical bills in emergency and non-emergency situations while also attempting to create a way for physicians and insurers to approach billing for such services. These “surprise bills” occur when a patient is charged for an out-of-network service or provider – such as a radiologist or anesthesiologist. For example, a patient may have a surgeon or hospital that is in-network and covered by a patient’s insurer, but the anesthesiologist may be out-of-network, which results in a “surprise bill” with little to no coverage by the insurer. While data suggests that roughly 90% of anesthesia services are in-network, which limits many surprise bills, anesthesiologists are often referenced in discussions of the issue.
While the goal was to protect patients, the bill’s language empowers insurance companies to strong-arm physicians, narrow provider networks, and ultimately reduce access to care. ASA, with concerns about patient access to care, has taken a stance against the bill and filed a lawsuit against the federal government. Current objectives for ASA members are exploring individual state legislature regarding surprise billing to see if it supersedes the federal law, utilizing the Independent Dispute Resolution (IDR) process to dispute insurer’s payments, and creating a key of “good faith estimates” of anesthesia service costs, which must be provided to surgeons for uninsured or self-pay patients. Without a doubt, the ramifications and potential resolutions of the No Surprises Act will impact all future anesthesiologists.
The 33% Problem
Medicare payments for anesthesia services have been undervalued for many years. In 1992 the Resource Based Relative Value Scale (RBRVS) was implemented to regularize program costs as they relate to Medicare payment rates. The new system ignored multiple types of anesthesia services, poorly accounted for time units, and utilized base unit values in a way which put them at a greater risk of adjustment than many other specialties. In short, this new RBRVS system suffered from calculation errors which resulted in a 29% decrease in Medicare payments for anesthesia services from 1991.
ASA has continued to work to address the misvaluation of anesthesia services. In 1995, the ASA helped secure a 16% increase in payments. In 2000 the ASA developed an analysis and proposed a 28% increase to the AMA Specialty Society Relative Value Scale Update Committee (RUC), but RUC only approved a 1.6% increase. In 2005 the ASA created a regression model to highlight the undervaluation of anesthesia services by Medicare, and ultimately helped secure a 23% increase. In 2005, Medicare still only paid 34% of commercial payer rates for anesthesia services, and that fell to 27% in 2020, partly due to inflation. In 2022 the Medicare anesthesia conversion factor should be $36.77 to be equivalent to the 1991 rate, but it currently sits at $21.56. In short, our 33% Problem has become a 25% problem. ASA is actively addressing these concerns and exploring solutions through lobbying and grassroots action.
Safe Anesthesia Care for Veterans (and the Stone Memo)
Pro-nursing factions with the U.S. Department of Veterans Affairs (VA) are working to eliminate anesthesiologists from VA’s Anesthesia Care Team and move VA to a CRNA-only model. Richard Stone, the former VA Under Secretary for Health and the spouse of a CRNA, issued a memorandum last year prior to his resignation, known as the “Stone Memo.” This memo came at the height of the pandemic and introduced a model for the VA to adopt the CRNA only practice. This past November the VA began undertaking the new Federal Supremacy Initiative, which requires the VA to standardize care in their facilities according to national standards of practice for all health professionals. These vaguely worded “standard of practice” requirements have been interpreted to favor the practices granting the most independence to CRNAs. This means that the Stone Memo could become permanent. The ASA is working with Veterans and grassroots movements to pass legislation which would return VA facilities to a standard of the physician anesthesiologist led team model.
Leading the Way Forward
These issues will play a major role in the future of every anesthesiology resident. As we advance our careers the curtains are pulled aside, we realize that those fighting for our rights are not as remote as we may think. It isn’t a secret group in a secret room that’s affecting legislation to protect ourselves and our patients. Rather, those esteemed individuals are program directors, committee members, resident leaders, and other driven individuals in each department.
Here's what’s at stake for our specialty:
- The No Surprises Act represents another way to try and limit patient’s access to safe anesthesia services while simultaneously reducing physician reimbursement.
- The 33% Problem could soon be a 10% problem unless we continue to battle for fair reimbursement.
- The Stone Memo and its effects further threaten the integrity and public opinion of our profession, while also subjecting patients to lower standards of care.
All these problems play off one another to weaken private and academic practices, lower demand for anesthesiologists, lower qualities of job satisfaction, and lower standards of patient care. These problems become very real for residents when attempting to find economically sound practices and fair contracts in order to pay loans, pay for a home, raise a family, etc. These problems become very real for patients when a lack of access to appropriate anesthesia services leads to increased morbidity and mortality rates.
If we don’t take pride in our profession and protecting it, then others will step up to steer it in a direction that best fits their discretion. Anesthesiology will always be best protected by anesthesiologists, and it is your job to be a part of the solution – not the problem. If unsure how to help, the best start would be to donate to ASAPAC. Beyond ASAPAC, do your best to be involved in leadership and committee opportunities. Use appropriate language and terminology within your department. Assert yourself as a competent and compassionate physician anesthesiologist every day to your co-workers and your patients.
How to Make a Difference
If motivated for leadership, make the effort to join committees and groups within your own hospital and department. Beyond the workplace, join State and ASA committees. Talk with the leaders within your own departments and take advantage of every single opportunity such as presentations, publications, memberships, etc. The more you do, the better you will understand the entire process. Just like growing competent in the OR, the only way to get better as a leader is to do more reps. Anesthesiologists are uniquely equipped as excellent communicators with a knack for leadership. Our prowess as board runners, OR supervisors, etc., already allows us to serve as leaders each and every day. Once you have your footing, some experience, and a reliable network; you can transition into specific roles which may fit your goals.
If interested to learn more, the ASA website is a terrific resource for the latest updates regarding our profession. The “Advocating for You” tab on the homepage offers links to further explore the No Surprises Act, the 33% Problem, the Stone Memo, and many more of the current issues facing our profession. The website also offers a multitude of resources for networking, leadership opportunities, education, etc. If you have any further questions, please do not hesitate to reach out to your local leaders, myself, or any member of your ASA Resident Component Governing Council.
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