www.mymsahq.org
IN THIS ISSUE: MEMBERSHIP MATTERS ASA LEGISLATIVE CONFERENCE RECAP
Summer 2016
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President John LaGorio, M.D. Norton Shores President-Elect Roy Soto, M.D. Bloomfield Hills Secretary-Treasurer Neeju Ravikant, M.D. Bloomfield Hills Immediate Past President Fred Campbell, M.D. Cedar Communications/ Public Relations Committee Ali Jaffer, M.D. Dominic Monterosso, D.O. Managing Editor Hillary Walilko
TAB L E OF CONT ENT S P R E S I DE N T ’S ME S SA GE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 D I R E C TO R ’S R E P O RT .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 C A L E N DA R O F E V ENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 R E SI DE N T R EV I EW: A S A L EGIS L ATIVE CO NF ER ENCE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 0 MS A P O L I T I C A L A CTIO N CO MMITTEE UP DATE.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 2 MS A ME MB E R S I N TH E NEWS .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 3 A S A U P DAT E S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 4 L E G I S L AT I V E C O R NER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 8
Contact for advertising information: Hillary Walilko MSA 120 N. Washington Square Suite 110A Lansing, MI 48933 Phone: 517.346.5088 Fax: 517.371.1170 email: walilko.h@gcsionline.com The Ventilator is published four times annually by GCSI Association Services. It is funded by the Michigan Society of Anesthesiologists and with advertising revenues. The Michigan Society of Anesthesiologists is a nonprofit, statewide organization. No part of this publication may be reproduced without permission of the publisher and MSA. All article submissions will be considered for publication and accepted at the approval of the Editor and the Communications/Public Relations Committee. We reserve the right to edit submissions for accuracy, clarity, and length.
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INDEX TO ADVERTISERS Anesthesia Business Consultants......................................................2 MedComm Billing Consultants........................................................9 Paragon Service.................................................................................19
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PR E S ID E N T ’ S M E SSAGE John LaGorio M.D. President
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was excited when I saw Michael Porter was going to be this year’s keynote speaker at Anesthesiology 2016 in Chicago, the ASA’s Annual meeting and largest educational anesthesiology meeting in the world. I’ve recently had the opportunity to read a bit of Porter’s work through my business studies. Since that time, recent events have made me come to look forward to his keynote with an increased interest. As you know, on June 7th Michigan lawmakers introduced a new bill, Senate Bill 1019, to eliminate physician involvement of anesthesia care for patients across Michigan. This new bill is nearly identical to Senate Bill 320. The MSA has been working for a year with members of the Senate Health Policy Committee on SB 320, offering amendments that went unanswered, and demonstrating to members of the committee the dangers of this legislation. As a result, committee members had rightly refused to take action on Senate Bill 320. In a desperate response, supporters of the bill created new, but almost identical legislation, and worked behind the scenes to put it before a new Senate committee. Of the last 18 bills to face the legislature on different healthcare scope of practice issues, this is the first and only to be referred to any committee other than Health Policy. The new committee held a hearing on SB 1019 on June 8th, just a day after the bill was introduced, and voted it out after only 10 minutes of testimony. The name of that committee?... Competitiveness. Michael Porter is a world renowned Harvard
Business School professor and economist. Much of Porter’s recent work has been in the economics of health care, with a focus on realigning delivery to maximize value to patients. Porter and his colleagues have introduced the core concepts for reorganizing health care organizations, measuring patient outcomes, understanding the actual cost of care, designing value-based reimbursement models, and integrating multi-location health systems. Porter’s background and much of the basis for his contemporary work is in, among other things… Competitiveness. Initially in his career, Porter developed theory and strategy concepts surrounding many of the most challenging problems facing corporations, economies and societies. With his beginnings as an aerospace engineer, initial focus was on industrial competition and company strategy. His theories helped to define modern corporate strategy and how companies should assess their competitive environment, position themselves, and implement tactics that lever the forces that shape industry competition. Later, Porter’s work began to look at how these microeconomic forces contribute to larger macroeconomic consequences and how corporations should incorporate social responsibility to provide for both corporate and social profitability. In Porter’s healthcare value agenda, the primary component is that clinicians should be organized into integrated practice units (IPU). In an IPU, a dedicated team of both clinical and non-clinical personnel provides full care cycle for the patient’s condition. One important element of the IPU
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is a physician team captain that oversees each patient’s care process. The strategy understands and values that a physician must remain involved and accountable to a patient’s care. A second component is that we must measure outcomes and costs that take into consideration factors that matter to patients. These might include survival, time to and degree of recovery, disutility (errors/complications), and sustainability of quality of life. A third component is to integrate delivery systems and work to provide improved geographic scale that best distributes patients to facilities appropriate to the services required.1 Physician anesthesiologists have made and continue to make tremendous impact on the safety and outcomes of patients throughout our state’s health delivery system on a daily basis. Studies have shown fewer complications and unexpected admissions when physician anesthesiologists are involved in care.2,3 We have also been cited to reduce cost of care through fewer consultations, cancelations, and testing.4 In addition, polls show that it is important to the vast majority of citizens that physicians remain involved in their anesthetic care.5 Whether that is personally performing an anesthetic, directing a care team, providing pain management or critical care, or providing care coordination; the scope of value that physician anesthesiologists bring to the full range of perioperative patients and services is unrivaled. It is incumbent upon all who advocate or legislate to keep in mind the social responsibility that comes with making healthcare policy decisions. It is necessary to properly understand the impact that placing these decisions in an inappropriate venue can have. Our state’s healthcare decisions cannot be unilaterally based in the context of arbitrarily self-defined competition, but instead need to be based on unbiased measurement of outcome, patient needs, and the individual and societal value that is derived from specific care efforts. Making these decisions based on the input of a few hospital association executives or others that act simply to increase revenue through a mechanism which removes services and safety nets from patients is short sighted and ill-informed. Just as Porter’s work began with competition and strategy, broadened to the impact on scalable economies, and finally incorporated the context Summer 2016
of social responsibility; so must legislators be aware to properly consider all aspects concerning possible healthcare legislation. It is incumbent upon us physician anesthesiologists to continue to seek and promote the value that is derived from our involvement in patient care. It is no longer enough to sit back, continue about our daily routine, and think the merits of our work are self-evident. There are those who will continue to strive to commoditize our services. Why? Because the result is a product that can be simply compared via nothing more than price and neglects the end impact on patients. We know better and live it daily. We need to proudly differentiate and measure our present accomplishments, and continue to create the vision of how we will impact transformation of healthcare from one based on volume to one focused on value. This begins in each of our individual practices, and continues as we share this with the public, hospital administrators, and our legislators. Please join me in doing this as the MSA broadens its communication plan over the remainder of this year. In addition, I hope to see you at Porter’s ASA keynote address in Chicago this fall as he discusses the role of physician anesthesiologists as the leaders in value-based healthcare delivery. References 1. Porter ME, Lee TH. The strategy that will fix healthcare. Harvard Business Review. Oct 2013 2. Silber et al. Anesthesiologist direction and patient outcomes. Anesthesiology. 2000 Jul;93(1):152-63. 3. Memtsoudis et al. Factors influencing unexpected disposition after orthopedic ambulatory surgery. J Clin Anesth. 2012 Mar;24(2):89-95. 4. Wiklund RA, Rosenbaum SH. Anesthesiology. N Engl J Med. 1997 Oct 16;337(16):1132 5. EPIC*MRA poll of live called 600 Michigan residents conducted January 24-27, 2015
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DIRECTOR ’S REPORT
Kenneth Elmassian D.O. ASA Director, Michigan Chairman, ASA Committee on Communications
MEMBERSHIP MATTERS
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ven though our MSA publication has touched upon the topic in the past, it is especially appropriate at this writing as your ASA Director to once again emphasize the importance of membership in your professional specialty societies, particularly as we welcome the incoming class of PGY1 anesthesiology residents who have chosen to continue their training in our State. Membership matters, and here is why…first and foremost, YOU are a professional, a physician, a healer. Your responsibilities are enormous, and your problems and the everyday practice challenges you are facing [and will face in the future] are not getting any smaller. This is true for the specialty, as well as for the practice of medicine. Whether it is the complexities of the electronic medical record, payment & billing issues, regulatory compliance, contractual agreements, business models, legislative issues not in the best interest of patient safety, or and even managing patient expectations, the ASA and the MSA are here to solve problems, recommend solutions, and guide you through the weeds and the landmines.
Take a moment to visit the ASA website www. asahq.org. You will find information on the latest Washington Alerts, and numerous educational opportunities, including registration links to the premier annual meeting of the ASA, ANESTHESIOLOGY 2016 [#ANES16] – lucky us, this year’s meeting is in Chicago! Regardless of your years of practice, there is something for everyone on the website. The staff in both Washington, DC and Schaumburg, IL, as well as your local state component office in Lansing [517 346 5088] are here to assist you. If you are still not convinced of the cost – benefits, here’s a link which will open your eyes to what bang you are getting for your buck…and particularly for residents [$25] and medical students [$10}, it’s the cheapest and most valuable item you will ever purchase, http://www.asahq.org/member-center/ roi-calculator
Representing over 54,000 physician anesthesiologists, the American Society of Anesthesiologists and its components are dedicated to the ASA’s mission of “Advancing the Practice, and Securing the Future”. Beyond this tagline, there is the real accompaniment, the so-called nuts and bolts, of what’s commonly referred to as the three legged foundation of this member -driven, specialty organization…advocacy, education, and research. McLaren Lansing PGY-1 Class (l to r) Jonathan Vu, D.O.; Ryan Pope, D.O.; and Joel Adelsberg, D.O.. 6 www.mymsahq.org
DMC/WSU Anesthesiology PGY-1 Residents Front row: (l to r) Rakshika Rajakaruna, M.D., Angela Snow, M.D., Marla Kerwin, D.O., Michelle Skewes, D.O., Kristin M. Sarkisian, D.O., Jesse Yarbrough, D.O. and Alyssa Risk, D.O. Back Row: (l to r) Shaan Jaggi, M.D., Cory Schall, M.D., Michael Wilson, D.O., Matthew Weeks, M.D., Andrew Schuldt, M.D., Hazem Mahmoud Alahwal, M.D.
Beaumont PGY-1 Residents (back row l to r) Leah Zhang, M.D., Patrick Stafford, M.D., Dana Burandt, D.O., Bradley Larson, M.D., Meagan McDavid, M.D., Laura Lepczyk, D.O.
WSU PGY-1 Residents (l to r) Christopher John, MD, Kristin Swenson, DO, Vennela Reddy, MD, Lisa Gilbert, MD, Spurthy Narreddy, MD, Hanish Singh, MD
Membership Matters cont. on Page 8 Summer 2016
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MEMBERSHIP MATTERS CONT. When taken into consideration the expenditures of belonging and participating in this organization and that organization, keep in mind you are investing in your future and the future of health care on behalf of your patients. As accomplished as each of you may be, we all arrived here on the shoulders of others, and it is your time to pay it forward! Join and/or renew today. Finally, as past president of the Michigan State Medical Society, and one of three anesthesiologists to serve in that role during the past four years, I would be remiss in not ending this article with the importance of joining and supporting your State medical society, as well. Regardless of specialty, and most importantly to the specialty of anesthesiology, I cannot speak enough to the synergy and interdependence between the MSA www.msahq.org, and MSMS www. msms.org.
https://www.facebook.com/AmericanSocietyofA nesthesiologists/?fref=ts https://www.facebook.com/Michigan-Society-ofAnesthesiologists-123931284376704/?fref=ts https://www.facebook.com/ MichStateMedSociety/?fref=ts We are here for YOU.
To all the new residents: Welcome to Michigan and don’t forget to Like and Follow the ASA, MSA and MSMS on social media. @asalifeline @asagrassroots @mymsahq @michstatemedsoc
Henry Ford Health System PGY-1 Residents
University of Michigan PGY-1 Residents Bottom row (l to r): Jessica Dominic, Karina Anam, Kelsey Serfozo, Jennifer Blume, Samantha Sutkamp, Monika Toton, Carolyn Foley, Katherine Rodenbeck, Omar Malas Top row (left to right): Suzanne Camp, Nikhil Iyer, Sarina Khan, Allen Haddad, Richard Sargent, Christopher Colonna, Storm Horine. 8 www.mymsahq.org
C A L E ND A R OF E V EN TS
2016
November 19 - 20 ASA QUALITY MEETING SCHAUMBURG, IL
September 14 MSA BOARD MEETING UNIVERSITY CLUB, LANSING
2017
October 21
March 11
THE MPOG/ASPIRE RETREAT CHICAGO, IL
MSA 62 ND SCIENTIFIC SESSION & ANNUAL MEETING ROYAL PARK HOTEL, ROCHESTER
October 22 - 26 ANAESTHESIOLOGY 2016 CHICAGO, IL
Visit www.mymsahq.org for current events and training opportunities.
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:: Capturing that documentation in an Electronic Health Record compatible with your external constituencies
:: Understanding how YOUR PRACTICE will fit into the world of the Affordable Care Act
:: Billing those coded procedures in a timely, efficient and complete manner
:: Taking care of your patients
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Summer 2016
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RESIDENT REVIEW: 2016 AMERICAN SOCIETY OF ANESTHESIOLOGISTS LEGISLATIVE CONFERENCE
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irst and foremost, we would like to express our gratitude to the MSA and our respective residency programs for allowing us to attend the ASA legislative conference in Washington, D.C. this spring. All of the residents in attendance knew advocacy was a challenging and important task prior to the meeting, and we all walked away with a much deeper appreciation for the profession’s advocacy efforts. It was enlightening to see how much organization and work goes into advocacy. The experience made us reflect on how we can all contribute - whether it is through a monetary donation to the political action committee (PAC) or by encouraging friends and family members to visit SafeVACare. org. The main focus of the American Society of
Anesthesiologist's political agenda was patient safety. The foremost issue discussed at this year’s ASA Legislative Conference was ensuring the safety of our veterans through a physician led anesthesia care model. Further, we discussed the opioid epidemic in our nation, and the steps anesthesia professionals can take to help curtail the problem. Ultimately, patient safety is at the center of our profession, and therefore it is aligned with our political agenda. We can help protect our patients' safety by contributing to our state PACs, as well as the national ASA PAC. This ensures that our collective voices are heard on Capitol Hill. It is a difficult task to discuss the numerous issues impacting anesthesiology with lawmakers in quick meetings lasting less than fifteen minutes. ASA members from around the country
Michigan physician and resident attendees at ASA Legislative Conference.
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2016 Resident attendees and MSA leadership prepare for Congressional visits.
gathered to surmount this difficult mission. Many great victories have already been won in Washington D.C. due to our state and national advocacy groups. However, it is clear that every physician anesthesiologist needs to contribute to our state and national professional political action committees to support and secure our professional interests. Finally, this year's ASA legislative conference was a great experience for all the residents involved. It was great spending time with anesthesia residents from all over the state and the country exploring the monuments and museums together. We
had the opportunity to learn effective advocacy techniques in addition to the importance of all our advocacy efforts for both our profession and our patients. This experience expanded our knowledge about the politics of anesthesia and allows us to educate our resident colleagues in each of our respective programs to all the advocacy challenges that our profession faces. Every day, we all deliberate about how our actions in the operating room can improve patient safety. It is now time to also consider how our actions in advocacy can optimize patient care. Political advocacy is as necessary to our profession as a secure airway is to our patients' safety.
2016 ASA LEGISLATIVE CONFERENCE MSA RESIDENT ATTENDEES James Jeltema, D.O., McLaren Lansing Nakul Kumar, M.D., Wayne State School of Medicine Jeffrey Olech, M.D., Henry Ford Health System Anna Pashkova, M.D., University of Michigan Patrick Robertson, M.D., DMC/Wayne State Boris Vidri, M.D., Beaumont Health Systems
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M SA PA C R E P ORT
MICHIGAN SOCIETY OF ANESTHESIOLOGISTS POLITICAL ACTION COMMITTEE UPDATE Michael Lewis, M.D. MSA PAC Co-Chair
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hope each of you is having a great summer. As many of you know I have only been a resident here in the great state of Michigan for nine months. I have had such a warm welcome from everyone it has been really amazing. In this MSA PAC report I wanted to give you all a little background.
In Lansing we are fighting Senate Bill 320, and now also Senate Bill 1019. This bill would facilitate independent CRNA practice. Let me be be very blunt, our fight on your behalf costs money and our reserves in this battle have dwindled down to their lowest level in years. We truly need your help.
For those of you who don’t know me- most of the time since I arrived in the USA in 1990 have been spent in Florida. I built my career at the University of Miami and was then Chair at the University of Florida College of Medicine in Jacksonville. While I was in Florida we had great success in advocacy both as a state and national PAC. We won the Alabama cup for six out of the last seven years. I was very involved in both statewide and national advocacy and my methodology was very much person to person communication- allowing the member to feel the urgency and the importance of the issues facing us. The pain had to be shared!
If you care about the remarkable safety record our profession has constructed over the years, PLEASE take a moment and made a donation to our war chest. It is very easy – just go to our website www.mymsahq.org, click on the about MSA tab, click on the MSAPAC tab, log-in and donate. It is a small action with a HUGE impact. Many thanks, Michael C. Lewis MD MSA PAC Co-Chair
I know some of the messages that I have sent out this year have been pretty direct. However, a brief survey of ‘anesthesiology politics’ both here in Michigan and on the national level show a pretty entropic environment. The nurses are arguing that we are are essentially irrelevant to the anesthesia care team. Core to their position is the irrelevance of the years each of us have spent in training and the contribution of our specialty to patient safety.
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MSA MEMBERS IN THE NEWS MSA Past President Kenneth Elmassian, D.O., East Lansing, has announced his 2016 candidacy for the office of Assistant Secretary of the American Society of Anesthesiologists. The contested election will be determined by the ASA House of Delegates on October 26th in Chicago held during ANESTHESIOLOGY® 2016, October 22 – 26. The ASA Assistant Secretary assists the ASA Secretary with membership, serves as the Credentialing Officer for the House of Delegates, Chairs the Section on Representation, serves as a liaison for the Resident and Medical Student Component Societies, and fulfills a leadership role as a member of the ASA’s Administrative Council. Dr. Elmassian is also past president of the Michigan State Medical Society (2013), he currently serves as Vice-Chairman, Department of Anesthesiology at McLaren Greater Lansing, and as Director of Cardiovascular & Thoracic Anesthesia. MSA Past President James Grant, M.D., Bloomfield Hills, will transition from 1st Vice President to PresidentElect of the American Society of Anesthesiologists at their annual meeting in October. Dr. Grant is chair of the Department of Anesthesiology at Beaumont Hospital-Royal Oak. He is also professor and chair of anesthesiology at Oakland University William Beaumont School
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of Medicine in Rochester. Dr. Grant is also past president of the Michigan State Medical Society (2014). Dr. Grant currently serves on the Board of Directors of The Anesthesia Foundation, the Foundation for Anesthesia Education and Research, and Blue Cross Blue Shield of Michigan. He is an associate examiner of the American Board of Anesthesiology and is the chair of the Michigan delegation to the American Medical Association. MSA Past President David Krhovsky, M.D., Grand Rapids, was installed as the 151st President of the Michigan State Medical Society in April. Dr. Krhovsky is the third anesthesiologist to serve as MSMS President in the past four years. A graduate of the Wayne State University School of Medicine, he is a past president of MSA, the Kent County Medical Society, and the KCMS Foundation. Dr. Krhovsky is on staff at Spectrum Health in Grand Rapids, and is a former President of the Spectrum Health Medical Staff. He currently serves as the Vice President of Medical Affairs at Spectrum Health.
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A SA UP D AT E S
THE APRN COMPACT: APRN INDEPENDENT PRACTICE IMPOSED ON ALL ADOPTING STATES Jeffrey Plagenhoef, M.D., ASA President Elect Erin Berry Philp, M.A., J.D., Senior State Affairs Associate
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hose 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, physicianled 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 so-called 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
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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 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 Summer 2016
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 15
A SA UP D AT E S c o nt.
ASA LEADERS PARTICIPATE IN FEDERAL OUT-OF-NETWORK PAYMENT ROUNDTABLE
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n April, 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-of-network 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-of-network 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 innetwork. 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.
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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
Summer 2016
as an emerging issue, the data still points to this being an important matter that impacts a very small percentage of patients. Proposed solutions to the challenge included references to states that are using an independent database of billed charges to address benchmarking for out-ofnetwork concerns. In addition to HHS’ consideration of out-ofnetwork payment, legislative efforts are pending in a number of states on this subject including prohibitions on balance billing, requirements for “good faith estimates,” out-of-network 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 j.hansen@asahq.org. © 2016 American Society of Anesthesiologists
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LE G IS LAT IV E C ORNER
New Legislation Introduced on Supervision and Scope of Nurse Anesthetists The issue of broadening the scope of practice for nurse anesthetists remains the highest priority of GCSI and the MSA. Previously we were fighting against Senate Bill 320, which was introduced by Senate Majority Floor Leader Senator Mike Kowall (R-White Lake) and removes the physician supervision requirement for nurse anesthetists and broadly expands their scope of practice. In an effort to partner constructively on the issue with members of the Senate Health Policy Committee yet protect patients, the MSA had proposed language that would keep intact physician supervision, but also allow the nurse anesthetists to increase their scope as originally suggested under the bill, such as permitting the nurses to become prescribers, so long as that authority is delegated by a physician. Last year, the Senate Health Policy Committee held one hearing on Senate Bill 320. However, as both the Michigan Association of Nurse Anesthetists (MANA) and the Michigan Health and Hospital Association (MHA) were again supporting this issue, our proposed amendments continued to be opposed by the supporters of the bill. As there weren’t enough votes in the Senate Health Policy Committee to move Senate Bill 320 without some amendments adding back in more physician involvement, the MHA and MANA instead asked for a new bill to be introduced on the issue and sent to another committee for consideration. The last week of session prior to the summer recess for the Legislature, Sen. Kowall introduced Senate Bill 1019 which also grants independent practice for nurse anesthetists as well as increasing their scope of practice. The bill was referred to the Senate Michigan Competitiveness Committee and it was voted on the day after introduction. The MHA again testified in support of the legislation
Legislative Corner is a regular feature, written by Marcia Hune and Chris Iannuzzi, Governmental Consultant Services, Inc.
and while MANA did not testify, they did submit a card of support for the bill. Those senators serving on the Senate Health Policy Committee have had experience in deliberating on scope of practice issues, including that of nurse anesthetists. However, they did not have the opportunity to weigh in on Senate Bill 1019 after they had already been vetting the same concepts in Senate Bill 320. The MSA and GCSI oppose the process that was used to “committee shop” the issue in order to move the bill to the floor. We continue to discuss our concern with regard to the process on the legislation as well as the concerns for patient safety under the bill with lawmakers in the State Senate and House of Representatives, as well as members of Governor Rick Snyder’s Administration. The bill is now before the full Senate for consideration. We again appreciate all of the MSA contacts that have been made to your lawmaker expressing concerns on the issue of independent practice for nurse anesthetists. We urge you to continue that outreach throughout the summer. GCSI continues to work diligently to be the eyes, ears, and representatives of the Michigan Society of Anesthesiologists in Lansing, as we advocate for policies that ensure the safety of patients. If members have questions, please do not hesitate to contact Marcia Hune or Chris Iannuzzi at hune.m@gcsionline.com or iannuzzi.c@gcsionline. com
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