Payments to Teaching Anesthesiologists: Policy Update 2004

1. Payments to Teaching Anesthesiologists: Policy Update2004 Alexander A. Hannenberg, M.D. Vice President for Professional Affairs American Society of Anesthesiologists Tufts University School of Medicine Newton-Wellesley Hospital Newton, MA

2. Welcome to Red Sox Nation !

3. History Medicare Policy on Teaching Anesthesiologists • Pre-1994 • Medicare Intermediary Letter (IL) 372 – Two full fees if “attending physician” relationship established • 1991 Final Rule • Implements Medicare Fee Schedule (RBRVS) • 29% Anesthesia Fee Reduction • Actual Time Preserved ! • Full Anesthesia Fee – one teaching case only. • Implementation Opposed – Delayed until 1994

4. Surgical Teaching Policy “In order to bill Medicare for two overlapping surgeries, the teaching surgeon must be present during the critical or key portions of the procedure.”

5. Medicare’s PRIT

6. Chronology: ASA & Teaching Rules • July 2003 -- ASA meets w/ CMS Administrator Scully & PRIT Staff • August 2003 – CMS proposes SRNA rules for teaching anesthesiologists • September 2003 – ASA comment – OK if (1) interim (2) optional alternative • December 2003 – Administrator Scully resigns • January 2004 – SRNA rules available • January 2004 – ASA meets PRIT staff re: 2005 rule change • March 2004 – Resident teaching rule change a “done deal” • May 2004 – ASA Legislative Conference: “on track” for Jan 05 • July 2004 – CMS Baltimore staff: ‘no change for 2005’ • August 2004 – Federal Register – no rule change proposed • August 2004 – ASA engages CMS lobbyists; Congressional & Administration interest developed • September 2004 – ASA files official comment

7. CMS Reverses ItselfJuly 20, 2004 • $34 MM Cost Estimate • Denies capacity to adjust within Part B pool • Anesthesiology Payment Consistent with “Time Based” Services • SRNA option impact not yet known.

8. Remaining Options • Demonstration Project • Stand-Alone Federal Register Notice of Rule Change • 2006 Implementation Date

9. 2005 Fee Schedule Final RuleNovember 15, 2004 • “…the teaching physician’s presence during the key or critical period criteria applies to both the services of the teaching surgeon and the teaching anesthesiologist. The key or critical services are different for the service of each specialty.” • “The AANA commented that our rules should not favor one type of provider over another.” • “ We plan to explore these issues further prior to deciding whether to include this change in the proposed rule for 2006.”

10. Poised for Victory • CMS Objections Addressed • Legal Foundation Established • Congressional Support Mobilized • White House Interest Developed

11. Workplan • Senate Majority Leader Role • Medicare Committees of Jurisdiction • Senate Finance Committee • House Ways & Means; Energy & Commerce • “All Politics is Local” • Focused Data Collection Tip O’Neill Speaker of the House

12. Private Payer Issues • ASA Role Limited by Anti-Trust Hazards • Medicare Solution Engineered to Control Private Payers • Payment Reductions via Modifiers • No HIPAA Requirement for Claims Modifier Use • Restoration of Full Fee in 2:1 Teaching • Instruction to Omit Modifier • Compensatory Conversion Factor Adjustment • Non-Participation (Contract Termination)