Indiana – Component Society News
IN Society of Anesthesiologists
July 2016
Indiana State Component Society Update
Message from ISA’s President
Dear ISA Member:
It is with great honor that I assumed the office of President of the Indiana Society of Anesthesiologists this past
February. I would like to gratefully acknowledge the strong leadership and service over the past two years of my
predecessor, Dr. William McNiece. I am very thankful that he will remain on the Executive Committee as the
Immediate Past President and continue to provide guidance on the important issues that we will face. I would
also like to welcome the newest member to the Executive Committee, Dr. Nicholas Datzman, who will serve as
Secretary-Treasurer. Dr. Seung Sim will now assume the role of President-Elect and continue to provide valuable
contributions to the ISA.
Each year brings new challenges to the provision of physician-led anesthesia care in Indiana. Whether it is
clinical, regulatory, or legislative, it is growing more and more important that anesthesiologists have a strong
and united voice. Your membership and participation are vitally important to the great care of Hoosier patients.
Annual Meeting
This year’s ISA Annual Meeting was held on February 20, 2016 at the Ritz Charles in Carmel. Many incredible
speakers gave excellent presentations and Dr. Stan Stead provided an informative ASA Update. Dr. Stephen
Dierdorf was honored with the Distinguished Service Award. Please see Dr. Sandra Kinsella’s article detailing his
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incredible career and contribution to anesthesia in Indiana. Thank
you to Dr. Seung Sim for chairing yet another fantastic meeting. Mark your calendars for the 2017 ISA Annual
Meeting on Saturday, February 11, 2017, at the Ritz Charles.
Practice Management Meeting
Save the date for the only state meeting devoted to anesthesia practice issues. The 2016 ISA Practice
Management Meeting will be held at the Ritz Charles on Saturday, September 10, 2016. Speakers will cover
topics including practice management basics, anesthesia leadership, the new MACRA-mandated physician
payment system, bringing anesthesiologist assistants into your practice, and other timely practice management
topics. This is a meeting not just for anesthesia leaders and administrators but to all anesthesiologists as we
struggle to understand the changes that are continuing to challenge the practice of anesthesia. More information
will be forthcoming in early August.
Anesthesiologist Assistants Licensure
The ISA’s multi-year effort to bring anesthesiologist assistants to Indiana reached a successful conclusion in late
April when the Medical Licensing Board issued its first AA license.
Although legislation authorizing AA licensure was adopted in 2014, the Board could not issue any licenses until
rules were promulgated that established the scope of practice for AAs and a process for licensure. These rules
were approved by Gov. Mike Pence in February and the Board signed off on the format of the application in
March. Less than three weeks later, Indiana officially became the 17th jurisdiction with AA practice when the
first AA license was issued. Information about AA licensure and a copy of the application are available online,
along with the regulations that govern AA practice. A presentation on the implementation of AA into a practice
will be presented at the ISA Practice Management Meeting on Saturday, September 10, 2016.
Legislative Issues
One of the most important functions of the ISA is in the area of advocacy. This is both an exciting and unusual
election year because of the presidential election. It is no less dramatic at the state level where a new
Governor, all of the State Representatives, and half of the State Senators are being elected.
We are saddened to hear the announcement from Senator Patricia Miller (R-Ind) that she will be retiring this
year. She has been a thoughtful legislator and a strong advocate of physician-led care over her decades of
leadership as the Chair of the Senate Committee on Health and Provider Services. She will be honored for her
years of service at the ISA Practice Management Meeting on September 10, 2016. Overall, it was a relatively
quiet year in relation to anesthesia-specific items but was significant for medicine in general because of the
changes to the medical malpractice act. In this newsletter, ISA lobbyist, Libby Cierzniak, has provided an update
of the 2016 session of the General Assembly.
Advocacy
Individual relationships with legislators are important to the ISA’s grassroots strategy. Take time to contact your
State Representative and Senator. I want to take a moment to recognize Dr. Tony Cheng from Fort Wayne for
hosting a very successful reception for Senator David Long, Senate Pro Tem. It is this type of engagement and
advocacy that will continue to solidify our relationships with legislators. One important future event which you
should support, includes an event for Representative Cindy Kirchhofer, Chair of the House Public Health
Committee. This event will take place on Thursday, August 25th, at the home of Drs. Alexander and Jennifer
Choi. Further information will be coming soon. BeIf you are interested in learning about how to get more
involved, please contact me at [email protected].
ISA PAC
Although there was no legislation regarding scope of practice expansions for non-physicians, we noted that the
Indiana Association of Nurse Anesthetists were at the State House for their first legislative day to meet with
various legislators and distribute information about the need for independent practice by nurse anesthetists. One
of the ways we combat this misinformation is through our own conversations with legislators. This is why your
participation in the ISA PAC is so important. The ISA PAC serves to accept donations that support the campaigns
of selected candidates for state office. In prior years, the ISA combined its membership renewal mailing with its
PAC donation request. This is no longer possible with unified billing so the ISA is using separate e-mailings.
Currently, about 13.5% of ISA members have made an ISA PAC contribution in 2016. This is substantially lower
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than the 21.4% of ISA members who had made a contribution by this time in 2015. I invite and encourage you to
make a 2016 contribution to the ISA PAC. You can make your contribution on line at https://isahq.net/memberssub1/ or by printing off the attached statement, writing a check made out to the Indiana Society of
Anesthesiologists PAC, and mailing it to the ISA office. Please encourage your colleagues to contribute to the ISA
PAC along with you.
VHA Nursing Handbook
The Department of Veterans Affairs’ (VA) Office of Nursing Services (ONS) proposed a document, the "Advanced
Practice Registered Nurses" rule or “VHA Nursing Handbook,” that would require “independent” practice for all
Advanced Practice Registered Nurses (APRNs), including CRNA’s, effectively abandoning the VA’s proven model
of physician-led, team-based anesthesia care. Both the ASA and the ISA strongly oppose the inclusion of the
surgical/anesthesia setting and nurse anesthetists in the VHA Nursing Handbook. Time is running out to provide
valuable comment back to the VA regarding the proposed rules. Before July 25, please go to
http://www.safevacare.org in order to comment on this issue. Furthermore, you can assist in the effort by
accessing the ASA web tools at https://www.asahq.org/advocacy/federal-activities/legislative-activity/vhanursing-handbook/asa-webinar-take-early-action-to-protect-safe-va-care/safe-va-care-webinar-materials. The
final rule on this will not only affect the VA health system, but be a long-term detriment to the provision of all
of our patients.
New Website
The ISA website has gotten a substantial face-lift that will allow us to provide resources to you in a much more
user-friendly format. Thank you to the Communications Committee (Drs. Datzman, Duque, Harrity, Montoya,
Park, and Sim), as well as, Wendy Gagnon and Alise Dillow for their time and efforts in this transformation.
Please visit www.isahq.net.
Sincerely,
Alexander Choi, M.D., M.P.H.
President
Indiana Society of Anesthesiologists
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ASA Legislative Conference 2016
Eleven ISA Board of Directors, including 4 anesthesia residents, attended the ASA Legislative Conference in
Washington, D.C. on May 16-18. The meeting focused on three important topics facing anesthesiologists: to
preserve safe care for veterans, MACRA, and to take action to address the prescription opioid abuse epidemic.
During the two days in Washington, the group met with Congressional members from Indiana. We were able to
meet with Representatives Brooks, Bucshon, Rokita, and Young. Additionally, the group met with the Health
Liaisons for Senators Donnelly and Coats, as well as, Representatives Carson and Visclosky.
The VA’s Office of Nursing Services has proposed a new policy document known as the “VHA Nursing Handbook”
which seeks to change how anesthesia care is delivered to our veterans receiving care in Veterans Health
Administration health care facilities. The new document abandons physician-led, team-based surgical anesthesia
care, replacing it with a nurse-only model of care. Our Congressional request was to ensure that the health and
lives of Veterans are not put at risk and to urge the VA to preserve physician-led, team-based surgical anesthesia
care in VA medical facilities by joining the Congressional sign-on letter or writing an individual letter to the VA.
The Medicare Access and CHIP Reauthorization Act (MACRA) repealed the flawed Sustainable Growth Rate (SGR)
formula and created a new Medicare physician payment system with two pathways for participation: Merit Based
Incentive Payment System (MIPS) and Advanced Alternate Payment Models (APMs). This was recently released in
April 2016. We discussed three key points during our Congressional meeting: appropriate timeline for
implementation, recognition of the role of physician anesthesiologists, and access to resources to develop
important quality measures.
It is necessary to implement strategies to reduce the misuse, abuse, and diversion of prescription opioid
medications. Our Congressional discussions included four key points: increase patient access to and physician
education on multimodal and multidisciplinary pain management and make naloxone more accessible to those
who might witness an opioid overdose, to reauthorize the National Substance Prescription Electronic Reporting
Act (H.R. 1725), to revise the pain management questions in the Hospital Consumer Assessment of Healthcare
Providers and Systems Survey, and to permit partially filled prescriptions for controlled substances.
On Tuesday evening Representatives Brooks and Rokita took the Indiana Delegation on a private tour of the
Capitol Building. The tour ended on the Speaker’s Balcony. From that vantage point, it is the most breathtaking
view of Washington, D.C. and the Washington Monument. It was truly a night to remember.
In follow-up, on May 25, 2016, the VA released its proposal, formerly known as the “VHA Nursing Handbook’
renamed as the “Advanced Practice Registered Nurses” proposed rule. This proposed rule will grant “full
practice authority” or independent practice to all Advance Practice Registered Nurses (APRNs) including nurse
anesthetists in the VA system. The proposal is now open for a 60 day comment period. The ASA is urging all
members to submit their comments to the newly revised website at www.SafeVACare.org by July 25.
Sandra B. Kinsella, M.D.
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Director’s Report
Without being a one string guitar, only playing one note, the message at this time is clear and focused: we must
correct the misguided “VHA Nursing Handbook” (aka Advanced Practice Registered Nurse Rule) issue. The efforts
being contemplated by the Veterans Health Administration would deprive our veterans of physician based care in
an environment when it is most critical. Organizationally, our ASA has carried the ball as far as we can. We must
now, each of us, take individual action. The APRN Rule has been published in the Federal Register and we only
have until July 24th to submit comments. We must also enlist our friends and family members to be involved.
The goal is a “1+5” program, each us getting five of our friends and family members to get involved by
expressing their opposition to this VA proposal. At some point, this will become a numbers game and we need to
get our number of comments up. The most recent communication I received from ASA on the issue was June 2nd.
It read as follows: "As of today, Indiana has recorded 796 comments thus far, which represents 89.33% of your
state's membership. Out of 50 states, the District of Columbia, and Puerto Rico, your state ranks 37 in comments
as a percentage of membership and 21 in total comments." I would hope to see us improve into at least the top
half, if not the top quarter.
If you do nothing else today, go to www.safeVAcare.org and make your voice heard. Then call at least five of
your friends and family members and get them to go to the site and register their opinion. This takes literally 90
seconds to accomplish.
The other big issue affecting each of you and your practices today is dealing with the new MACRA legislation and
regulations. If your practice manager has not gotten started on dealing with the new regulations and Qualified
Clinical Data Registry (QCDR) reporting requirements, they need to start immediately. 2016 is in play when it
comes to calculating future potential penalties from Medicare payments. CMS failed to release its QCDR
reporting regulations until the end of April, yet the entire calendar year of 2016 is part of the reporting process.
So, CMS has already created a tall mountain for each of us to climb. Those of us who visited our Congressional
representatives in Washington in May brought this issue to their attention, but it is unlikely that Congress will
grant us any grace period when it comes to QCDR reporting. Review this MACRA and QCDR issue on the ASA
website, asahq.org, for more information.
Gerard T. Costello, M.D.
ASA Director, Indiana Society of Anesthesiologists
Robert W. Brandt, M.D.
Alternate ASA Director, Indiana Society of Anesthesiologists
ISA Annual Meeting
Save The Date: The 2017 Indiana Society of Anesthesiologists Annual Meeting will be February 11, 2017 at the
Ritz Charles in Carmel, Indiana.
Indiana Society of Anesthesiologists Distinguished Service Award
The Indiana Society of Anesthesiologists Distinguished Service Award may be given annually to an ISA member.
The award recognizes exemplary service to the profession and the ISA. The type of service is unspecified and
may include outstanding clinical, educational or scientific achievement, contributions to the specialty and/or
exemplary service to the Society. The names of prior recipients of the award can be found at
http://isahq.net/dsa-recipients/. Nominations for this award should include the nominator's name and contact
information along with the nominee's name and a letter in support of the nomination. It would be helpful to
include a copy of the nominee's CV. Nominations should be submitted to William McNiece, M.D., Chair, ISA
Distinguished Service Award Committee, at [email protected] no later than August 19, 2016.
William McNiece, M.D.
Resident’s Report
During the third week of May, four resident delegates of the ISA were privileged to attend the 2016 ASA
Legislative Conference in Washington, D.C. There we heard from a variety of accomplished speakers concerning
the state of anesthesiology in the U.S., and learned valuable skills such as communicating with policymakers and
developing leadership skills, amongst many other discussions. The conference culminated with members of the
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Indiana Delegation meeting with our representatives from
Congress to discuss a variety of important issues. At the forefront was the topic of the VA Nursing
Handbook, and how important it was to maintain the team-based model of anesthesia care for the VA Healthcare
System. We were also able to discuss the current opioid abuse epidemic and to explain our thoughts concerning
MACRA. Overall, it was a very enlightening and eye-opening conference for us all; and we are passing along this
experience with our resident colleagues to continue gathering support as we fight for the safety of our veterans.
Just as the ASA and ISA are reaching out in regards to the “Advanced Practice Registered Nurses” proposed rules,
formerly known as the “VA Nursing Handbook,” the resident delegates are urging engagement from the other
residents. We are stressing the 1+5 suggestion from the ASA. The goal is at minimum 100% participation from
residents with hopes that they become further engaged with this issue as well as others such as those mentioned
above. As many past IU residents know, a great deal of learning comes from the VA, especially with regards to
managing patients with multiple comorbidities and providing a safe anesthetic. It is our hope to maintain the
current structure that has been so beneficial over the years and ensure future residents are not placed in a
situation that in any way impacts their training.
In other news, the 2016 NRMP Main Residency Match occurred just a few months ago. This year saw an
unprecedented 55 PGY-1 anesthesiology positions go unfilled. With that being said, we are proud to say that the
Indiana University Department of Anesthesiology filled all 26 of its positions. We look forward to welcoming a
new class of physicians to our program starting July 1st. We are planning on engaging them in ISA, ASA, and their
associated PACs and establishing physician leaders early in their training.
A great thanks to David Owens and Will Mulvoy for their efforts these last three years as resident delegates. They
have played a huge role in increasing membership and PAC participation during their tenure. We plan to build on
all of their hard work and efforts.
Jason C. Miller, M.D.
CA-2 Delegate
Ross B. Mirman, M.D.
CA-1 Delegate
Legislative Update
There was no shortage of activity in the health arena during the 2016 “short” legislative session. Between the
opening day in early January and the final gavel on March 10, state lawmakers took action on a wide range of
proposals affecting health care providers, including measures aimed at curbing Indiana’s opioid epidemic (SEA
214, HEA 1278), expanding treatment options for persons struggling with addiction (SEA 297, HEA 1347), and
establishing standards for health care providers who prescribe via telemedicine (HEA 1263).
But the most surprising turn of events was an 11th – hour compromise between the Indiana State Medical
Association, the Indiana Hospital Association, and the Indiana Trial Lawyers Association that resulted in the first
increase since 1999 to the cap on damages under the state’s Medical Malpractice Act.
Although a med mal reform bill had died earlier in the session amid stakeholder disagreement, the parties
continued to work toward a compromise. The final language was amended into a bill that originally restricted
the maximum height of fences (SEA 28). Key provisions include:
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Maximum payout: Increases the maximum payout from $1.25 million to $1.65 million for injuries
occurring between July 1, 2017 and June 30, 2019, and to $1.8 million for injuries occurring after July
30, 2019.
Provider’s share: Increases the provider’s maximum share from $250,000 to $400,000 for injuries
occurring between July 1, 2017 and June 30, 2019, and to $500,000 for injuries occurring after July 30,
2019.
Attorney fees: Caps attorney fees at 32% of the recovered amount for acts of malpractice committed
after June 30, 2017.
Anesthesiologist assistants: Includes AAs as qualified providers for purposes of individual coverage
under the Medical Malpractice Act.
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Summaries of all the new laws passed by the 2016 General
Assembly that potentially impact anesthesiologists may be found at this link. More significant, however, is what
didn’t pass.
For the first time in several years, the Indiana Association of Nurse Anesthetists did not push to expand CRNA
scope of practice. However, IANA did amp up its presence at the Statehouse, holding a first-ever CRNA advocacy
day and also joining with a coalition of advanced practice nurses to host a luncheon for legislators. Based on this
increased activity, it’s possible that IANA is laying the groundwork to push for independent practice legislation in
2017, when the Senate Health & Provider Services Committee will no longer be chaired by retiring Sen. Pat
Miller. A registered nurse, Sen. Miller has a clear understanding of the difference in training and experience
between physicians and nurses, and has been cautious in her approach to legislation that would expand nonphysician scope of practice.
Now that the dust has settled on the 2016 session, state lawmakers have begun to turn their attention to the
work of legislative study committees. Several issues impacting physicians are slated for review this summer by
the Interim Study Committee on Public Health, Behavioral Health, and Human Services, including multi-state
nurse licensure compacts. As discussed in greater detail in the June 2016 issue of the ASA Monitor, nurse
anesthetists in other states have pushed for adoption of the multi-state APRN compact as a backdoor means to
independent practice. Although it’s unclear at this point whether the APRN compact will be part of the panel’s
review, ISA will be closely monitoring study committee activity and will provide testimony and information as
needed to help ensure that patient safety is foremost in the minds of committee members as they craft
recommendations for proposed legislation.
The ISA’s multi-year effort to bring anesthesiologist assistants to Indiana reached a successful conclusion in late
April when the Medical Licensing Board issued its first AA license.
Although legislation authorizing AA licensure was adopted in 2014, the Board could not issue any licenses until
rules were promulgated that established the scope of practice for AAs and a process for licensure. These rules
were approved by Gov. Mike Pence in February and the Board signed off on the format of the application in
March. Less than three weeks later, Indiana officially became the 17 jurisdiction with AA practice when the first
AA license was issued.
Information about AA licensure and a copy of the application are available online, along with the regulations that
govern AA practice.
Libby Cierzniak, J.D.
American Society of Anesthesiologists 2015 Annual Meeting
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October 22 – 26, 2016
Chicago, IL
For additional details:
https://www.asahq.org/meetings/calendar/2016/10/copy%20of%20anesthesiology2016
For a calendar of events: https://www.asahq.org/meetings/calendar
Join us in Chicago at the ASA Annual Meeting for “Indiana Night”
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Sunday, October 23, 2016
6 – 8 PM
The Hilton Chicago
This is always a fun time catching up with friends and colleagues.
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2015 ISA Distinguished Service Award
On February 20, 2016, Stephen F. Dierdorf received the Distinguished Service Award during the Annual Meeting
of the Indiana Society of Anesthesiologists. Following the meeting there was a celebratory reception and dinner.
Dr. Dierdorf was most deserving of this award due to his extensive service to anesthesiologists in the state of
Indiana and nationally. He began his career in 1976 after completing his residency in anesthesiology at Indiana
University School of Medicine. He served 2 years in the Navy and then returned to the Department of Anesthesia
at IUSOM as an Assistant Professor in 1978 and promoted to Professor in 1990. He served on the ISA Board of
Directors, serving on the Executive Committee from 1982-1988 and President of the ISA from 1986-1988. Just to
mention a few of his accomplishments, he became a nationally recognized leader in airway management and
developed and participated in numerous workshops for the ASA in the management of the difficult airway. He is
published in over 22 peer reviewed journals, written numerous book chapters, guest lecturer throughout the US
and in Europe, and coeditor of Anesthesia and Co-Existing Diseases.
Stephen Dierdorf dedicated his career to the education of all Anesthesiologists and the future Anesthesiologists
in Indiana. He retired from the Department of Anesthesia at Indiana University School of Medicine in July 2015.
He and his wife live in South Carolina. Although retired, he still works two days a week at the Medical College of
South Carolina in Charleston.
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Updates
Federal Legislative Update
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Final Consensus Opioid - Prescription Drug Abuse Legislation Includes Key ASA-Backed Provisions
House and Senate Committees Pass Appropriations Bill with Nursing Handbook Language
VA Re-emphasizes Team-based Anesthesia in Senate; AANA Holds Press Conference
Federal Regulatory Update
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ASA Launches Veteran-focused Safe VA Care Comment Site
ASA Submits Comments on the MACRA Proposed Rule
Payment and Practice Management Update
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CMS Releases Proposed Rule for 2017 Medicare Physician Fee Schedule
Timely Topics in Payment and Practice Management
o New ICD-10-CM Codes for Unintended Awareness Under General Anesthesia (July 2016)
o Updates to the Recovery Audit Program (June 2016)
o CMS Policy Change: Unused or Discarded Drugs (June 2016)
o MACRA Implementation: Pulse Checks along the Way (May 2016)
o Is Your ICD-10 Transition Still on Track? (May 2016)
o Medicare Appeals Process (April 2016)
o Advance Beneficiary Notices (April 2016)
Public Relations Update
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Physician Anesthesiologists Urge Americans to Oppose VA Policy Abandoning Team-based Anesthesia Care
in Surgery
Orthopaedic Surgeons Announce Involvement in ASA’s Perioperative Surgical Home Care Model
ASA president discusses Safe VA Care on FOX News Special Report with Bret Baier
FOX News Radio highlights ASA press briefing denouncing dangerous VA policy change
Washington Post features American Society of Anesthesiologists’ position on proposed VA rule
United Press International article on proposed VA rule quotes ASA president and past president
ASA Encourages Action to Protect Safe VA Care
With less than 10 days left of the 60-day public comment period (comments due July 25), it is especially
important for ASA members to speak up to protect safe, physician-led care in VA. In addition to submitting
comments at SafeVACare.org, and encouraging others to do so as well, ASA members will now have the
opportunity to speak to the VA directly in their communities.
ASA members are encouraged to attend local community forums to discuss the importance of preserving
physician-led anesthesia care for Veterans and concerns with the negative impact of the proposed "Advanced
Practice Registered Nurses" rule on safe, quality care for Veterans. Please check this regularly updated list for an
opportunity near you. Please contact ASA Government and Political Outreach Manager Amanda Ott with
questions about events in your area.
Additionally, we continue to encourage ASA members to make their voice heard on the VA issue in other ways—
both politically and in the media. Members are urged to reach out to their Governor, state representatives, state
medical associations, and local Veterans Service Organizations to share concerns on the VA proposed rule and
urge these individuals to contact VA directly. If you are looking for other ways to let your voice be heard, you
can also submit a letter to the editor of your local newspaper. Contact [email protected] for submission guidelines
and word counts for your local paper.
Please contact [email protected] for additional information on VA outreach or if you would like assistance
writing a letter to a state leader, organization, or newspaper. You can also find a number of VA outreach
materials on ASA’s website, available here.
© 2016 American Society of Anesthesiologists
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ASA Member Elected to AMA Board of
Trustees
On June 14, ASA member William A. McDade, M.D., Ph.D., was elected to the Board of Trustees for the American
Medical Association (AMA). Dr. McDade is a longtime member of ASA’s delegation to the AMA. He is also a past
president of the Illinois State Medical Society and presently serves as chair of its Board of Trustees. He joins
another ASA member Jesse M. Ehrenfeld, M.D., M.P.H., on the AMA’s Board of Trustees. Dr. Ehrenfeld was
elected in 2014.
Dr. McDade is the deputy provost for research and minority issues and an associate professor, Department of
Anesthesia and Critical Care at the University of Chicago. He also is a director with the Accreditation Council for
Graduate Medical Education and is immediate past chair of the AMA’s Council on Medical Education. In 2012, he
was named the Chicago Medical Society’s “Physician of the Year.” This July, Dr. McDade will begin his newest
role as Ochsner Health System’s executive vice president and chief academic officer.
Dr. McDade’s election is the result of years of service as a physician leader. With the ever growing list of matters
on which the AMA is called to weigh in, it is critical that physician anestheisologists be a part of the discussion.
Whether it be scope of practice, insurance, allied team member, or related issues, having physician
anesthesiologists at the table is required for the promotion and protection of the specialty.
Congratulations Dr. McDade!
© 2016 American Society of Anesthesiologists
New Scope-of-Practice Publications
Two studies co-authored by ASA Health Policy Research about the anesthesia opt-out rule were recently
published in peer-reviewed journals. Each used a different data set (Medicare claims and the National Inpatient
Sample) to examine the effect of opting out on access to anesthesia services. Of the 17 governor opt-out letters,
10 specified access to anesthesia care as being relevant to the opt-out decision. However, both of these recent
studies found that opting out has not improved access to anesthesia services. Download the full studies on the
ASA Health Policy Research webpages (http://www.asahq.org/resources/health-policy-research).
Study citations:
Sun EC, Miller TR, Halzack NM. In the United States, “opt-out” states show no increase in access to anesthesia
services for Medicare beneficiaries compared with non-“opt-out” states. A&A Case Reports. 2016; 6(9):283-5.
Sun EC, Dexter F, Miller TR. The effect of “opt-out” regulation on access to surgical care for urgent cases in the
United States: Evidence from the National Inpatient Sample. Anesth Analg. 2016; 122(6):1983-91.
Additionally, a cost effectiveness analysis comparing anesthesia delivery models was recently accepted for
publication in the Journal of Clinical Anesthesia. Check the Health Policy Research web pages for future updates
about its publications!
© 2016 American Society of Anesthesiologists
ASA® 2016 ANESTHESIA ALMANAC
The ASA 2016 ANESTHESIA ALMANAC is a compilation of perioperative data for the United States recently
published by ASA Health Policy Research (HPR). It includes information about surgical volume, anesthesia
utilization trends, anesthesia workforce characteristics and practice acquisitions collected from a variety of data
sources.
The ANESTHESIA ALMANAC includes simple figures and detailed tables that may be useful for meetings with
policymakers or conducting additional analyses. It is free to access and can be downloaded from the HPR
webpages (http://www.asahq.org/resources/health-policy-research).
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We also expect that the ANESTHESIA ALMANAC will change from
year to year and encourage you to submit any comments or suggestions to the ASA Health Policy Research
Department at [email protected] or call Thomas R. Miller, Director of ASA Health Policy Research at (847) 2689215.
© 2016 American Society of Anesthesiologists
ASA Leaders Participate in Federal Out-of-Network Payment Roundtable
On April 27, as part of ASA’s ongoing work related to out-of-network payment issues, ASA First Vice President
James D. Grant, M.D., and Sherif Zaafran, M.D., chair of ASA’s Ad Hoc Committee on Out-of-Network Payment,
represented ASA at a meeting with leadership of the U.S. Department of Health and Human Services (HHS) in
Washington, D.C. concerning the rising problems with out-of-network payment. The meeting, arranged by HHS,
served as a forum for HHS leadership to elicit feedback from provider stakeholders about initiatives needed to
address the topic.
The President’s HHS 2017 Budget provides that “[i]n an effort to promote transparency on price, cost, and billing
for consumers, the Budget supports the standardization of billing documents and eliminating surprise out-ofnetwork charges for privately insured patients receiving care at an in-network facility.”
Out-of-network payment, commonly termed “surprise bills” or “balance billing,” occurs when a patient receives
a bill for the amount remaining between the out-of-network provider’s fee and the amount contributed by the
patient’s insurer after copay and deductibles. In most cases, balance billing is the result of a large gap between
what the insurer chooses to pay in an out-of-network setting and the physician’s billed charge. Per the FY 2017
Budget in Brief, “Hospitals would have to take reasonable steps to match individual patients with providers that
are considered in‐network for their plan. Furthermore, all physicians who regularly provide services in hospitals
would be required to accept an appropriate in‐network rate as payment‐in‐full. Thus, if the hospital failed to
match a patient to an in‐network provider, the patient would still be protected from surprise out‐of‐network
charges.”
Recognizing the evolving impact out-of-network payment has on advocacy and public relations efforts of state
component societies, in 2015 ASA’s Executive Committee approved an Ad Hoc Committee on Out-of-Network
Payment (AHCONP) which is developing advocacy materials and providing support to states engaged in out-ofnetwork payment initiatives. Drs. Zaafran and Grant, through AHCONP, have been working with a number of the
physician stakeholder groups represented at the meeting, leading to dialogue where the medical societies were
building off one another to help HHS understand the nuances and complexities of this insurance industry created
problem patients are enduring.
Dr. Grant helped the group understand that even in elective surgeries, complications and emergencies occur that
sometimes require other health care professionals who may not be in-network. Dr. Zaafran highlighted the need
for a Patient’s Bill of Rights, that an out-of-network deductible apply to an in-network deductible, and that
insurers must have an adequate number of physicians in the plans they sell. The Bill of Rights would outline
patient rights, provide a solution for what really is an insurance gap, and advise how to know what the insurance
product is as well as what is and what is not covered.
At the event, attendees shared that the challenge with this topic is as much about patients being unaware of
what their plans actually cover as it is about the unexpected bill they receive. As it stands, providers may know
their charges but are not aware of a carrier’s payment for the health services to be rendered, especially with
the complex array of different insurance products offered to consumers. As such, while patients are responsible
for educating themselves on their coverage, the insurers must be made to be more forthcoming with
information. Moreover, insurers should do more to educate patients so when they schedule a procedure/surgery,
others - such as a physician anesthesiologist, radiologist, or pathologist - may be involved and it is important to
determine their network status as well.
With the complexity of plans, the narrowing of networks and increasing use of network tiers where a provider
may be in one tier and not the other, the carriers were again noted as the single source for where patients could
go for such information. The group also discussed that while the media has promoted out-of-network payment as
an emerging issue, the data still points to this being an important matter that impacts a very small percentage of
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patients. Proposed solutions to the challenge included references
to states that are using an independent database of billed charges to address benchmarking for out-of-network
concerns.
In addition to HHS’ consideration of out-of-network payment, legislative efforts are pending in a number of
states on this subject including prohibitions on balance billing, requirements for “good faith estimates,” out-ofnetwork disclosure/consent requirements for non-emergency services, and mediation triggered by a minimum
price threshold. HHS will likely seek more information on out-of-network payment and ASA will continue to
report the efforts of ASA physician leadership to educate policymakers on this important subject.
For more information, contact Jason Hansen, Director of State Affairs, at [email protected].
© 2016 American Society of Anesthesiologists
Florida Governor Signs Out-of-Network Payments Legislation
On April 14, Florida Gov. Rick Scott (R) signed into law legislation (Chapter No. 2016-222) requiring new payment
processes for out-of-network providers of emergency and nonemergency services. The legislation was strongly
opposed by the Florida Society of Anesthesiologists (FSA) and a number of stakeholders including the Florida
Radiological Society, and only received final Senate passage in the waning hours of the last day of the session.
The legislation was effective July 1, 2016.
Most importantly, the measure details new processes for payment to providers of emergency and nonemergency
services when the provider is not a preferred provider at a facility that is in network. Specifically, the new law
requires that an insurer pay a nonparticipating provider (such as a physician anesthesiologist) of such services, as
follows, reduced only by insured cost-share responsibilities as specified in the health insurance policy and within
the applicable provided timeframe:
Reimbursement for services shall be the lesser of:
•
•
•
The provider's charges;
The usual and customary provider charges for similar services in the community where the services were
provided (which is not defined in law and will be determined only if contested which involves a financial
burden on the provider); or
The charge mutually agreed to by the insurer and the provider within 60 days of the submittal of the
claim.
This new law is very concerning as it removes any patient responsibility whatsoever, even in nonemergent
settings, and places insurers in the position of independently dictating payment for emergency and
nonemergency health services. Under this law, providers are at the whim of insurers’ determination on usual and
customary charges as no independent benchmarking system is provided within the language.
FSA, ASA, and other stakeholders strongly encouraged Governor Scott to veto this ill-considered measure.
Recognizing the evolving impact out-of-network payment has on advocacy and public relations efforts of state
component societies, the Executive Committee (EC) approved an Ad Hoc Committee on Out-of-Network Payment
(AHCONP), chaired by Sherif Zaafran, M.D. Internally, AHCONP is initially focusing efforts on developing public
relations, legislative strategy, and payment benchmarking resources. Externally, AHCONP is leading efforts to
ensure medical specialty organizations are working together on these issues. The American Medical Association
(AMA) recently held a CEO in-person meeting on this subject. An in-person meeting, hosted by ASA and the
American College of Emergency Physicians, of the physician leaders and applicable staff of the medical
specialties took place in May.
Should you have any questions or are in need of assistance with current or pending out-of-network payment
legislation in your state, please contact Director of State Affairs Jason Hansen at [email protected].
© 2016 American Society of Anesthesiologists
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Washington D.C. Increases Certified
Anesthesiologist Assistant Supervision Ratio
On April 8, 2016, the D.C. Department of Health approved a rule increasing the supervision ratio for Certified
Anesthesiologist Assistants (CAAs) in the District of Columbia. Specifically, the rule increases the number of CAAs
a physician anesthesiologist may supervise from three to four. This increase will provide District residents
greater access to the safe and effective care CAAs provide. The rule is effective immediately and can be viewed
here.
CAAs are highly skilled health professionals who work within the direction of physician anesthesiologists to
implement anesthesia care plans. They work exclusively within the Anesthesia Care Team environment as
described by the American Society of Anesthesiologists (ASA). All CAAs possess a premedical undergraduate
background and complete a comprehensive didactic and clinical program at the graduate school master’s degree
level. They are trained extensively in the delivery and maintenance of quality anesthesia care as well as
advanced patient monitoring techniques.
The D.C. Society of Anesthesiologists (DCSA) worked with the D.C. Department of Health to help advance this
regulation. Both DCSA and ASA submitted formal comments in support of the proposal. Congratulations to the
DCSA on this achievement!
To learn more about initiating certified anesthesiologist assistant legislation in your state, please feel free to
contact Ashli Eastwood, State Affairs Associate, at [email protected].
Read ASA’s comments in support of the proposed regulation.
© 2016 American Society of Anesthesiologists
ASA Member Elected President of Massachusetts Medical Society
On May 5, ASA member James S. Gessner, M.D. was elected president of the Massachusetts Medical Society. Dr.
Gessner is a past president of the Massachusetts Society of Anesthesiologists and currently serves as chair of its
Judicial Committee. Dr. Gessner also is a past president of the New England Society of Anesthesiologists and
currently serves as its secretary-treasurer.
Board certified in anesthesiology and pediatrics, Dr. Gessner currently works in private practice and is an
assistant professor of Anesthesiology at Boston Medical Center. He received his medical degree from Harvard and
completed his residency in anesthesiology at Peter Bent Brigham Hospital.
Physician anesthesiologists are currently serving as president or president-elect of state medical societies in
other states including Georgia, Michigan, and Utah. Serving within the leadership of a state medical society is an
incredibly important component of an effective advocacy program. As state medical societies consider advocacy
related policies and positions, it is vital for physician anesthesiologists to be involved in those discussions. As
these leaders bring their expertise to the state medical societies, anesthesiology is better informed and most
importantly, represented.
We congratulate Dr. Gessner on his accomplishments!
© 2016 American Society of Anesthesiologists
ASA Physician Leader Becomes President of the Michigan State Medical
Society
On April 29, longtime ASA member David Krhovsky, M.D., became president of the Michigan State Medical
Society. Dr. Krhovsky is an ASA alternate director for the Michigan Society of Anesthesiologists and previously
served as president. He serves as vice president of medical affairs at Spectrum Health Hospital Group – Grand
Rapids. Dr. Krhovsky received his medical degree from Wayne State University in Detroit and completed his
residency at Detroit Medical Center.
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Physician anesthesiologists are currently serving as president or
president-elect of state medical societies in other states including Georgia, Massachusetts, and Utah. Serving
within the leadership of a state medical society is an incredibly important component of an effective advocacy
program. As state medical societies consider advocacy related policies and positions, it is vital for physician
anesthesiologists to be involved in those discussions. As these leaders bring their expertise to the state medical
societies, anesthesiology is better informed and most importantly, represented.
Congratulations, Dr. Krhovsky!
© 2016 American Society of Anesthesiologists
The APRN Compact: APRN Independent Practice Imposed on All Adopting
States
By Jeffrey Plagenhoef, M.D., ASA President Elect and Erin Berry Philp, M.A., J.D., Senior State Affairs
Associate.
Those of us who are involved in state advocacy have witnessed numerous advocacy attempts by nurse
anesthetists and advanced practice registered nurses (APRNs) in general to eliminate existing requirements for
patient-centered, physician-led care. Many times, legislation or proposed regulatory language is obvious in its
attempt to abandon the care team model, but sometimes … well, sometimes an incremental approach takes such
a long time to implement, the last steps in the process can be downright shocking. This is the case with the socalled APRN Compact.
We have been aware of the APRN Consensus Model for several years and have tried to inform ASA members about
this dangerous trend. In a nutshell, the APRN Consensus Model is 2008 draft state legislative language developed
by the National Council of State Boards of Nursing (NCSBN) that gives the APRN title to four roles of advanced
practice nurses: nurse anesthetists, nurse practitioners, nurse specialists, and nurse midwives. Although it is
usually touted by APRNs as simple name change legislation, nothing could be further from the truth. If you
Google “APRN Consensus Model,” you can read the draft language yourself; the language increases scope of
practice for APRNs – including nurse anesthetists – and makes them independent practitioners. The Consensus
Model toolkit on the NCSBN website clearly states that APRNs are to be licensed as “independent practitioners
with no regulatory requirements for collaboration, direction or supervision.”
Many states have enacted parts of the APRN Consensus Model, with most of them picking and choosing language
and not changing their already-standing statutes or regulations regarding the team care model. A majority of
states now lump all advanced practice nurses into the “APRN” categorization. You may be asking, “why does a
name matter? What does it matter what we call advanced practice nurses?” It matters because even a small
name change is a huge step in an incremental plan by APRNs to remove physicians as leaders of the care team.
Last year, the NCSBN approved draft legislation titled the “APRN Compact.” The compact would allow APRNs
who hold a multistate license to practice in other compact states. The NCSBN says that in order to be considered
a compact state, a state must pass the draft legislation without “any material differences.” Unlike the
Federation of State Medical Boards’ Interstate Medical Licensure Compact, the APRN Compact seeks to
automatically eliminate physician involvement requirements for APRNs who practice under a multistate license.
Additionally, if one reads the entirety of the legislation, you’ll see that the term “APRN” is never defined. All
the “simple name change” bills states have passed mean that nurse anesthetists automatically fall under the
term “APRN” for the purpose of this compact.
Article III, Section (h) of the legislation says:
This means if an APRN (including a nurse anesthetist) receives a multistate license under the compact, he or she
would be able to function independently, regardless of what the party state’s law says.
Forty-six states and the District of Columbia, by statute or regulation, require nurse anesthetists to work in a
team-based relationship with a physician (not necessarily a physician anesthesiologist), whether through
physician supervision, collaboration, direction, consultation, agreement or other arrangement for the delivery of
anesthesia services. The APRN Compact would completely usurp these states’ laws and regulations. Words
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matter. Legislators and regulators carefully chose language to
indicate that nurse anesthetists must work in those kinds of relationships with physicians when providing
anesthesia care within their state lines.
Other sections of the draft legislation say that the APRN Compact will govern licensing. This takes many
decisions away from state boards of nursing and puts it in the hands of the NCSBN, who will govern the APRN
Compact. An outside organization will have authority to say who should or should not receive an APRN license.
The APRN Compact carelessly brushes aside laws and regulations crafted by states’ democratically elected
legislators or executive-appointed regulatory boards, all in the interest of gaining independent practice by any
means necessary.
The APRN Compact fails to recognize the crucial difference between primary care and surgical anesthesia/
critical care. Removing physician involvement (any physician, not just physician anesthesiologists) from
anesthesia compromises patient safety. Nurse anesthetists are a valued member of the anesthesia team, but
removing physician involvement from anesthesia care makes no more sense than removing it from any other
critical care location. We are not trying to keep advanced practice nurses from obtaining a multistate license,
but we are opposed to it when the mechanism to do so usurps state laws pertaining to patient safety. This is an
underhanded attempt to eliminate the physician-led care team patients rely on in states where advanced
practice nurses have not been able to do so via obvious legislative means.
The APRN Compact language says that only 10 states have to enact the compact into law to have it go into
limited effect. So far during the 2016 legislative session, Idaho, Iowa and Wyoming saw the APRN Compact
introduced, and Idaho and Wyoming signed it into law. Some have said, “my state is one of the four states that
has independent practice for nurse anesthetists. What does it matter if we pass the Compact?” Please do your
part to keep the APRN Compact from going into effect! With Idaho and Wyoming now Compact states, only eight
states stand between APRNs gaining automatic independent practice in every Compact state under a multistate
license. Even some state boards of nursing are acknowledging that the APRN Compact is over-the-top. During an
April 2015 Texas Board of Nursing meeting, the board discussed the APRN Licensure Compact and noted their
board should abstain from accepting Article III (h) “since such provision is not authorized under Texas law.”
Article III, Section (h) is not authorized under 46 state laws and regulations!
For the remainder of this legislative session, and in preparation for the 2017 legislative session, determine the
definition of “APRN” in your state. It’s also important to monitor regulatory boards to make sure they are not
unilaterally changing definitions in state regulations, as well. We must vigorously oppose the APRN Compact in
its current format in order to prevent the usurpation of state laws regarding patient safety. For more
information about the APRN Compact and what you can do in your state, contact Jason Hansen, Erin Philp or
Ashli Eastwood.
© 2016 American Society of Anesthesiologists
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