2017 Fall Sentinel Newsletter

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Fall 2017

Pennsylvania Society of Anesthesiologists Newsletter


The Future Is Now by Bhaskar Deb, M.D. PSA President

www.psanes.org Telephone (717) 558-7750 ext. 1596

The pillars of strategic planning for PSA are constituted of Advocacy, Quality & Practice Advancement, Educational Resources, Member Experience, continued on page 22

Member experience

Educational Resources

Quality and Practice Advancement


in his quest and asks all PSA members to demonstrate strong support for his success in the 2018 election cycle. Looking to the future, I have initiated a Strategic Planning Committee for PSA. The Committee is a diverse group representing different regions of the state and practice models. Assisting us with our planning and implementation efforts, will be the CEO of ASA, Mr. Paul Pomerantz. I will outline some of the goals for the Committee and PSA Board. First and foremost, PSA

Health System Leadership and Organizational Growth

must become nimble in these changing times. Our Articles of Incorporation have not been addressed in 50+ years and our bylaws do not allow us to make changes quickly. We must reconstruct the pillars upon which PSA strands.

Business Development

I am very pleased to inform you that Dr. Richard O’Flynn, past PSA president (2013-2014) and present board member has announced his candidacy for State Representative (R) for the 161st District (Delaware County). There has not been any physician representation in the state legislature for over 50 years. In these difficult political times, Dr. O’Flynn’s goal of becoming a legislator will be invaluable to us. The 161st District has traditionally been held by a Republican with a 5,000 Republican voter majority in the District. He is a lifelong resident of Delaware County, his wife is also an anesthesiologist and member of PSA. Rich will champion our causes for patient safety issues, out of network billing, and issues related to the opioid epidemic. It is clear physician input has been lacking in the legislature; having a physician within the ranks will be extremely helpful. PSA leadership supports Dr. O’Flynn

Fall 2017

Contents Is There a Doctor in the House?


Z-PAC Update


New Informed Consent Requirements: Physician Duty to Obtain Informed Consent Non-Delegable


Issues of Current Interest to Anesthesiologists


Fewer Cowboys, More Pit Crews


Physician Anesthesiologist Jerome Adams, M.D. Named U.S. Surgeon General


On the Other Side, When a Doctor Becomes the Patient


Is Collaboration Necessary or Even Helpful?


PSA Eastern PA Regional Meeting and Dinner


Insurance Prior Authorization Delays Harm Patients Doctors Must Be Part of the Solution! PAGE 18

2016-2017 Officers President Bhaskar Deb, M.D.



Pennsylvania Society of Anesthesiologists Newsletter

Association Director Libby Dietrich

Richard Month, M.D.

Vice President Tom Witkowski, M.D.

Past President Andrew Herlich, M.D.

Editor Richard P. O’Flynn, M.D.


President Bhaskar Deb, M.D.

Asst. Secretary/Treasurer

Margaret M. Tarpey, M.D. Patrick J. Vlahos, M.D.

The PSA Newsletter is an official publication of the Pennsylvania Society of Anesthesiologists Inc. Opinions expressed in this newsletter do not necessarily reflect the Society’s point of view. All correspondence should be directed to: PSA Newsletter 777 East Park Drive, P.O. Box 8820 Harrisburg, PA 17105-8820 717/558-7750 ext. 1596



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District IX Director Erin A. Sullivan, M.D.

Alternate District Director Joseph F. Answine, M.D.

Delegates to the ASA House of Delegates Joseph F. Answine, M.D. Joshua H. Atkins, M.D., Ph.D. Robert A. Campbell, M.D. Bhaskar Deb, M.D. Joseph W. Galassi, Jr., M.D. David M. Gratch, D.O. Andrew Herlich, M.D. Kristin Ondecko Ligda, M.D. Richard Month, M.D.

Pennsylvania Society of Anesthesiologists Newsletter

Craig L. Muetterties, M.D. Richard P. O’Flynn, M.D. Margaret M. Tarpey, M.D. Thomas Witkowski, M.D.

Alternate Delegates to the ASA House of Delegates Albert A. Belardi, M.D. Andrew Boryan, M.D. Lee A. Fleisher, M.D. Shannon Grap, M.D. Mark Hudson, M.D. Randy E. Lamberg, M.D. A. Joseph Layon, M.D. Philip A. Mandato, D.O. Donald E. Martin, M.D. Ben Park, M.D. Shailesh Patel, M.D. Mark J. Shulkosky, M.D. Anthony T. Silipo, D.O. Patrick J. Vlahos, D.O.

Alternate Delegates, Pennsylvania Medical Society House & Specialty Leadership Cabinet Donald E. Martin, M.D. Shannon Grap, M.D.

Carrier Advisory Representative Gordon Moorewood, M.D.


Is There a Doctor in the House? Is there a doctor in the House? It turns out there is not even one, nor has there been one since anyone can remember. Let me explain. The Harrisburg legislature consists of 50 Senate members comprised of 34 Republicans and 16 Democrats. The House has 202 members with 121 Republicans and 81 Democrats. The total breakdown for physicians versus non-physicians is 252-0. Doctors are outnumbered at this point in time. Have you noticed that Harrisburg health policies too often compromise patient safety? Have you noticed that politicians’ priorities are self-serving and do not address the pressing needs of physicians or our patients? Have you taken time from your increasingly hectic practices to realize these policies are diminishing actual physician involvement in delivering high quality healthcare? Have you noticed the avalanche of



Rich O’Flynn, M.D. for State Representative (R) for the 161st District (Delaware County)

often irrelevant regulatory and administrative burdens that have become barriers to physiciancentered patient care? Could it be one reason for the emergence of failed policies from Harrisburg is there is not one physician member of the Pennsylvania House or Senate? Physicians need a voice in Harrisburg. Without a Doctor in the House, these kinds of policies will continue to pour out of Harrisburg leading our noble discipline into the abyss.



Dr. Rich O’Flynn is taking the road least traveled. He is taking time from his busy medical practice to run for the 161st House seat in Delaware County. Rich has served PSA in so many ways over the past 25 years in addition to being a fulltime practicing anesthesiologist in Pennsylvania for the same duration. He is well versed in the issues confronting the practice of anesthesiology in Pennsylvania. He is a past president of our Society, and has spent tireless hours in Harrisburg on behalf of PSA members and our patients. Rich is running as a Republican and will likely face both a Republican Primary opponent and then a Democrat incumbent. Rich is characteristically focused and not intimidated by the obstacles he will encounter in the upcoming campaign. We wish him well in his run for State Representative!

Robert Campbell, M.D.




Pennsylvania Society of Anesthesiologists Newsletter

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Z– PAC Update by Craig L Muetterties, M.D. Z–PAC Treasurer

As the newly-named treasurer for the Pennsylvania Society of Anesthesiologists Political Action Committee, I want to take some time to talk about the importance of Z-PAC. Paul Schaner, M.D., a long-time board member and Past President of our Society, formed Z-PAC 30 years ago. He recognized the need for our Society to have a presence in Harrisburg that could respond to legislation brought about by other special interest groups that would harm patient safety and negatively impact the practice of medicine. Dr. Schaner was truly a visionary. At the time the committee was formed, it was one of the first specialty society political action groups in existence, pre-dating the ASA Political Action Committee. While the Society itself was engaged in keeping track of legislation that addressed patient safety and the practice of anesthesia, Z-PAC contributions from members like you opened the doors to discussions between legislators and physicians. These discussions are crucial and they cannot be limited to discussions initiated by board members with legislators from distant areas of the State. Your legislators want to see YOU. I am writing this to encourage each of you to become the face of our profession with your local representative and senator. We need local physicians to establish communication with these legislators. Having you hand deliver a PAC contribution is a great way to initiate a


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relationship. You may be so busy in your daily life that you do not even know the identity of your representative. You are not alone in this situation. By inputting your address into this site (http:// www.legis.state.pa.us/cfdocs/ legis/home/findyourlegislator/) you will be able to get the name, contact information and location of the local office for your senator and representative. Stop by the office and get to know the staff. Email me and let me know whom you have visited. I may need

I personally have that deduct money from my checking account or credit card on a monthly basis. One of them is the Wall Street Journal. I do not want to be seen as person who reads news while at work, so I rarely get a chance to use my subscription—a waste of money! I usually find myself logging on to one of the Internet search engines for latest news when I awaken. My WSJ subscription is nearly $25 a month—that translates to $300 a year! I never even notice when

I encouraged you to follow this link: http://www.legis.state.pa.us/cfdocs/legis/home/ findyourlegislator/ you to stop by and drop off a contribution check from the PAC in the future. My first visit to Sen. Pileggi’s office was just that—a visit. I stopped by unannounced only to find out that the Senator was in Harrisburg. His office staff impressed me with their friendliness. One of the staff persons repeated my name after she heard it, “Muetterties! I think I have seen that name recently. It was on a list of unclaimed funds. May I help you apply for them?” I walked out of the office that day receiving a lot more then I had expected as I entered. Lastly, I would like to address the crucial importance of REGULAR giving to the PAC. No one likes writing a large check on a yearly basis. There are a number of services that

Pennsylvania Society of Anesthesiologists Newsletter

I am paying for this. For those of you who do not like writing large checks, I suggest a monthly payment. A deduction of $84 a month from a credit card or checking account would result in over $1,000 donated to the PAC fund, with little or no pain. Over the coming weeks I will be changing the way credit card processing occurs within the fund to allow for monthly payments. I encourage anyone who has not contributed before to consider this easy way of helping to ensure patient safety and the viability of your occupation in the future.

New Informed Consent: Requirements Physician Duty To Obtain Informed Consent Non-Delegable by Charles I. Artz, Esq. PSA General Counsel

The Pennsylvania Supreme Court published a landmark ruling on June 20, 2017 explaining a physician’s duty to provide information to a patient sufficient to obtain legally valid informed consent. This applies to every procedure that is subject to the Informed Consent requirements under state law, summarized below. Failure to follow the new law could result in medical malpractice liability even if the standard of care was satisfied. Accordingly, this is an extremely important decision with significant clinical and operational implications. In Shinal v. Toms, 162 A.3d 429 (Pa. 2017), the plaintiff sued the physician, a neurosurgeon, for failure to obtain informed consent before the surgical procedure, which was not successful. The unsuccessful surgery was a “bad outcome” resulting in significant injuries, but no negligence was alleged to have occurred, i.e., the physician did not breach the standard of care. The patient sued

the physician for failure to obtain a valid informed consent before surgery. Understanding the informed consent procedure used in this case is imperative. The patient met with the surgeon and discussed alternatives, risks and benefits of various options. A few weeks later, the patient met with the physician’s physician assistant (“PA”) and had more discussions about the procedures and alternatives. A month later, the patient again met with the PA. The PA obtained the patient’s medical history, conducted a physical and provided the patient with information relating to the surgery. At the visit with the PA, the patient signed an informed consent form. The informed consent gave the physician permission to perform the procedure and identified the risks of the surgery to include pain, scarring, bleeding, infection, breathing problems, heart attack, stroke, injury and death. The form also indicated the patient discussed the advantages and disadvantages of alternative treatments; that everything had been fully explained to the patient; that the patient understood the form’s contents; and the patient had the opportunity to ask questions and was given sufficient information to give her informed consent to the operation. Although a prior discussion may have addressed the specific risks of the actual procedure

undertaken, the form did not. The patient’s lawsuit based upon lack of valid informed consent was premised on the allegation that, had she known the alternative approaches to all of the surgical procedures explained by the physician, she would have chosen a safer, less aggressive alternative. At the trial, the physician raised the defense that the informed consent was valid. The judge instructed the jury that the jury could consider any relevant information communicated to the patient by any qualified person acting as an assistant to the physician, including the PA. The jury returned a verdict in favor of the physician. The patient appealed, arguing the jury instruction was incorrect and that they should not have considered any relevant information communicated to the patient by any qualified person, including the PA, and that the only person obligated to obtain full informed consent was the physician himself. Before analyzing the Supreme Court’s holdings and rationale, it is important to understand the informed consent requirements under the MCARE Act, which defines informed consent as follows: (a) Duty of physicians. Except in emergencies, a physician owes a duty to a patient to obtain the informed consent of the patient or continued on page 6

Pennsylvania Society of Anesthesiologists Newsletter

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NEW INFORMED CONSENT continued from page 5 the patient’s authorized representative prior to conducting the following procedures: (1) Performing surgery, including the related administration of anesthesia. (2) Administering radiation or chemotherapy. (3) Administering a blood transfusion. (4) Inserting a surgical device or appliance. (5) Administering an experimental medication, using an experimental device or using an approved medication or device in an experimental manner. (b) Description of procedure. Consent is informed if the patient has been given a description of a procedure set forth in subsection (a) and the risks and alternatives that a reasonably prudent patient would require to make an informed decision as to that procedure. The physician shall be entitled to present evidence of the description of that procedure and those risks and alternatives that a physician acting in accordance with accepted medical standards of medical practice would provide. (c) Expert testimony. Expert testimony is required to determine whether the procedure constituted the type of procedure set forth in subsection (a) and to identify the risks of that procedure, the alternatives to that procedure and the risks of these alternatives. (d) Liability. (1) A physician is liable for failure to obtain the informed consent only if the patient proves that receiving such information would have been a substantial factor in the patient’s decision whether to undergo a procedure set forth in subsection (a).


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(2) A physician may be held liable for failure to seek a patient’s informed consent if the physician knowingly misrepresents to the patient his or her professional credentials, training or experience. 40 P.S. §1303.504. The patient appealed the jury’s verdict in favor of the physician to the Superior Court, and ultimately to the Supreme Court. The Supreme Court’s holdings and rationale include the following: 1. The physician argued that, while it is the physician’s duty to obtain the patient’s informed consent, the physician is not required to supply all of the information personally. Instead, it is the information conveyed, rather than the person conveying it, that determines informed consent. 2. The Supreme Court rejected that argument and held that a physician’s duty to provide information to a patient sufficient to obtain her informed consent is non-delegable. A physician cannot rely upon a subordinate (including a physician assistant or anyone else) to disclose the information required to obtain informed consent. 3. The Supreme Court reasoned that, without direct dialogue and a two-way exchange between the physician and patient, the physician cannot be confident that the patient comprehends the risks, benefits, likelihood of success and alternatives to the procedure. A physician cannot delegate the provision of critical information to staff, because it would undermine patient autonomy and bodily integrity by depriving the patient of the opportunity to engage in a dialogue with his or her chosen health care provider. Nothing in §504 of the MCARE Act suggests that conversations between the patient and others can control the informed consent analysis or can satisfy the physician’s legal burden.

Pennsylvania Society of Anesthesiologists Newsletter

4. A physician may not delegate to others his or her obligation to provide sufficient information in order to obtain a patient’s informed consent. Informed consent requires direct communication between physician and patient, and contemplates a back-and-forth, face-to-face exchange, which might include questions that the patient feels the physician must answer personally before the patient feels informed and becomes willing to consent. The duty to obtain the patient’s informed consent belongs solely to the physician. 5. Without the patient’s informed consent, the physician is liable for the procedure, regardless of whether the physician was negligent. This means failure to obtain valid informed consent exposes the physician to liability for damages even where the physician was not negligent and the standard of care was not breached, and the injuries were caused by a nonnegligent bad outcome. The Supreme Court’s new decision overrules two previous Superior Court decisions which allowed delegation of informed consent to physician assistants and other qualified personnel. It means the physician must be directly involved in the entire informed consent process, including all discussions and explanations of the risks, benefits, likelihood of success and alternatives with the patient in a face-to-face encounter. Failure to have the physicians conduct the entirety of the informed consent process exposes physicians to liability for damages based upon lack of a valid informed consent even though the physician was not negligent and the standard of care was not breached, and the only problem was a bad outcome. This is a significant change in the law and is effective immediately upon publication of the Supreme Court’s decision on June 20, 2017.

The Supreme Court’s decision did not contemplate how a physician’s non-delegable duty to obtain informed consent affects anesthesia practices, and the practicality of how informed consents are obtained for scheduled surgeries. PSA has considered many questions and scenarios from its members. Below is a consolidated list of frequently asked questions regarding the informed consent process for anesthesia care related to the recent PA Supreme Court Decision: Q. Who is able to provide the informed consent discussion for anesthesia? A. The Supreme Court decision holds that a physician may not delegate to others his or her obligation to provide sufficient information in order to obtain a patients’ informed consent. The Court also indicated that informed consent requires direct communication between physician and patient, and contemplates a back and forth, face to face exchange, which might include questions that the patient feels the physician must answer personally before the patient feels informed and becomes willing to consent. Physicians may no longer use the assistance of physician colleagues, residents, PAs, CRNPS, CRNAs or any other practitioners to perform the duty. Q. Often a patient has been seen preoperatively by one anesthesiologist but, due to the nature of anesthesia care, a second anesthesiologist is responsible for initiating anesthesia care. Is a second informed consent process necessary? A. According to the decision, the physician performing the surgery or treatment “owes the patient” the discussion necessary to obtain informed consent. If the patient is mentally capable of the discussion, the second anesthesiologist should provide the information and allow the “face to face, back and forth exchange” and also sign, time and date the Consent form, indicating that they provided the discussion and when it occurred. There is a reasonable argument that a new Consent Form does not have to be completed or signed by the patient. If the change of personnel occurs after the patient has been sedated to the point of not being able to participate, hospital counsel have advised anesthesiologists to proceed with the anesthetic. Q. Many hospital departments and divisions obtain informed consents in clinics and they are not certain who the operating surgeon or attending anesthesiologist will be on the day of the actual surgery (e.g. anesthesia clinic, OB surgery, plastic surgery and pediatric surgery). Who should obtain the informed consent and sign the informed consent form in the clinic based on this practice? A. The Supreme Court decision does not contemplate this question specifically. It appears that one reasonable approach would be for the attending physician from the division or department, who is one of the physicians who could be operating

FAQ’s or administering or overseeing the anesthesia, should obtain the consent and fill out the form at the clinic visit. If possible, any internal informed consent forms should continue to list all of the physicians who could be involved. If the attending surgeon or anesthesiologist was not the physician who obtained the original informed consent, PSA recommends the physician (a) acknowledge with the patient on the surgery/ procedure date that his/her colleague, Dr. _________, previously obtained the consent; (b) ask the patient if they have additional questions for the anesthesiologist today; and (c) have a new form signed that day by the patient and the attending physician. This appears to best meet the spirit of the law while recognizing how this works in practice. Q. Can CRNAs obtain consent if they will be administering the anesthesia with attending physician oversight? A. No. The attending physician must obtain the informed consent. Q. Often transfer of care of a patient occurs from one anesthesiologist to another during the anesthesia. If that occurs, do we need to prospectively identify the second anesthesiologist to be involved with the consent process or contact a family member or power of attorney? A. No Q. Are the residents/fellows or CRNAs allowed to provide any information to the patient? A. The specific discussion regarding risk, benefits, and alternatives sufficient for the patient to provide consent must be done personally by the attending physician anesthesiologist who is credentialed and privileged by the facility to be ultimately responsible for the anesthetic. The resident/ fellow or CRNA can answer questions regarding specific technical and process elements of the anesthetic and can provide the patient with the Anesthesia Consent form for review. Any questions specific to risk, benefits, or alternatives are to be referred to the attending physician anesthesiologist. Only the attending physician anesthesiologist should sign the form as the person who provided the informed consent discussion. Q. In some facilities, nerve blocks are performed by one anesthesiologist and a second anesthesiologist is responsible for the intraoperative anesthetic. Often these patients receive sedatives during the block. Because of this, the consent for both the nerve block and the anesthesia is often obtained by the anesthesiologist performing the block. How do we handle this situation? A. Nerve blocks are performed as either blocks for postoperative pain (separate from the anesthetic) or for surgical anesthesia. If

for surgical anesthesia, a single consent form and consent process for the anesthetic can be provided by the anesthesiologist performing the block without the anesthesiologist responsible for the intraoperative care having to do anything else (treated like a transfer of care, as the anesthetic has been initiated with placement of the nerve block). If the nerve block is for post-operative pain, two informed consent processes should occur: one for the block; and one for the anesthesia. The recommendation of some facilities, if the consents cannot be coordinated knowing the physicians to be involved in the anesthesia care, is to continue to have the physician performing the block provide the discussion and obtain the signed consent for both. When the anesthesiologist who is responsible for the anesthesia care is known, and if the patient is able participate, a second discussion takes place by that anesthesiologist, who provides his signature additionally in the physician line of the consent form. If the patient is unable to participate, the recommendation is to proceed with the anesthetic. Q. This decision poses particular problems with ICU patients for whom we have to obtain consent from family members or powers of attorney (“POA”). Currently, some facilities attempt to obtain these consents the night before, by the call or late anesthesiologists, to prevent delays the morning of surgery. Does the consent discussion still need to be by the anesthesiologist responsible for the anesthetic the day of surgery? A. Ideally, the consent discussion should be performed by the anesthesiologist responsible for the anesthetic the day of surgery. Specific work flow changes based on current practice at the sites are likely necessary. If the physician responsible for the anesthesia is unavailable or unknown, the discussion can take place by any physician anesthesiologist, with the consent form completed as is currently done. During discussion with the family or POA, a phone number or other contact information should be obtained and documented prominently to allow the responsible physician to perform the required discussion the day of surgery. Q. Some facilities have the availability of a 30-day consent form. This ruling suggests that we will no longer be able to use this form? A. Correct. Because the informed consent discussion is owed by the physician anesthesiologist responsible for the anesthetic the day of surgery, a 30-day consent form is no longer legally viable, and the consent discussion must take place prior to each procedure unless the actual attending anesthesiologist is known, meets the patient, and discussed the anesthetic sometime before the day of surgery.

Pennsylvania Society of Anesthesiologists Newsletter

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Issues of Current Interest to Anesthesiologists by Shannon Grap, M.D. and Donald Martin, M.D. PA Medical Society Specialty Leadership Cabinet Update

At the most recent PAMED Society Specialty Leadership Cabinet (SLC) Meeting on August 15, several important issues were discussed that impact both our specialty of anesthesiology and our patients at large in Pennsylvania. The SLC continues to be supportive of our efforts in advocacy for our specialty and patients, and provides a voice for anesthesiology within the PA Medical Society. A summary of important and ongoing topics is provided below: • The issue of out of network (OON) payment continues to be front and center, as Senate Bill 678 and House Bill 1553 gain momentum, despite physician opposition. Insurance companies are seeking ways to increase market power and profits, leading to the narrowing of coverage networks. Many patients are receiving unexpected payment requests for gaps in coverage due to increases in insurance cost sharing and narrower networks, especially for


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hospital based specialties, including anesthesiology. However, patients are incorrectly perceiving these unexpected costs as increases in physician bills. The proposed legislation of SB678 and HB1553 would provide insurers the power to determine which physicians can care for a patient within a network and what direct services can be provided. Under these proposals, physicians must bill and are paid by insurers. Therefore, physicians would in fact work for insurers rather than patients, and these Bills could give insurance companies more power to determine or withhold treatment. PSA has joined forces to oppose these bills with other hospital-based physician groups that would be most impacted by this legislation, including emergency medicine, pathology, and radiology. The SLC and Pennsylvania Medical Society (PAMED) support our opposition, and will aid us in efforts to

Pennsylvania Society of Anesthesiologists Newsletter

educate our patients that gaps in coverage are not due to increased physician billing. Ongoing lobbying efforts are also occurring with State legislators through PSA leadership, and patient education will be paramount. You will receive more information on how you can support the critical opposition to these bills and materials to aid in patient education. • The prior authorization initiative is a grassroots campaign that was originally formed by the SLC and supported by PAMED in order to prevent insurance companies from denying and delaying patient access to medical care and treatment. While prior authorization issues often do not directly impact anesthesia services, they do significantly affect our patients at large in Pennsylvania. PAMED has teamed with a coalition of 40 different agencies and patient advocacy groups to gain momentum in support of House Bill 1293 which seeks to streamline the prior authorization process and prevent delays in medical care. HB1293 was introduced in April by Rep. Marguerite Quinn (R-Bucks) and has now been referred to the House Insurance Committee. In order to attract attention from legislators, and especially members of this Committee, this initiative is dependent on our efforts to increase patient awareness and supporting

patients to share their stories. Please encourage all those who have experiences with delays in care or treatment due to insurance prior authorizations to share their stories on PAMED’s website. PAMED also offers patient education materials, the names and districts of the members of the House Insurance Committee, legislative talking points, and direct ways to contact your Pennsylvania House member at https://www.pamedsoc.org/ advocate/topics/credentialingand-insurance-reforms/ PriorAuthBill. Following the Pennsylvania Supreme Court decision regarding Informed Consent in Shinal vs. Toms in June, many hospitals have modified the consenting process for the

administration of anesthesia and surgery. Although the court ruled that it is the physician’s “non-delegable duty” to obtain informed consent prior to surgery and anesthesia, many hospitals and healthcare networks have had varying interpretations of their ruling. PSA Counsel, Charles Artz discusses this ruling and the impact on anesthesia departments in detail in the article titled New Informed Consent: Requirements Physician Duty To Obtain Informed Consent Non-Delegable on page 5 of this newsletter. While the Supreme Court ruling requiring physician anesthesiologists as responsible for obtaining informed consent supports our model for physician anesthesiologist led team-based

care, many physicians are finding themselves in the middle between legal interpretations and the lack of appropriate hospital systems for patient flow and care delivery in obtaining consents prior to anesthesia. PAMED has been gathering data from Pennsylvania physicians regarding the impact of the Supreme Court decision on physician practice and patient care. This information will be presented to PAMED for further review and recommendations moving forward. Our efforts in advocacy for high value and timely patient care are crucial for these legislative movements. We must continue with a unified and persistent voice to express concerns on behalf of our patients. Please visit PAMED’s website at www.pamedsoc.org for more information and resources.

Saturday and Sunday May 5 - May 6, 2018 Penn State Milton S. Hershey Medical Center, Hershey, PA Saturday Evening Dinner and Discussion with Keynote Speaker Colin McCartney, MBChB, PhD, FRCA, FCARCSI, FRCPC Professor & Chair of Anesthesiology, University of Ottawa

Internationally known faculty

Registration opens Fall 2017

Basic and Advanced Tracks; small group sizes

Discounted rates for Fellows , Residents, and PSA members

Hands-on practice on cadavers

Multi-Media didactic sessions and volunteer scanning

Optional sessions on pediatric & one-to-one hands-on practice

For more Information, see the PSA website at www.psanes.org and http://hmc.pennstatehealth.org/anesthesiology-andperioperative-medicine

Bring Your Family to Hershey Park!!

For more information, contact Chris Mulvey at 717-531-7988 or email cmulvey@pennstatehealth.psu.edu

Pennsylvania Society of Anesthesiologists Newsletter

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Reformation of the U.S. Healthcare System (Part 2):

Fewer Cowboys, More Pit Crews by Gordon Morewood, M.D., MBA, FASE Professor and Chair, Department of Anesthesiology Lewis Katz School of Medicine at Temple University Anesthetist-in-Chief, Temple University Health System

On May 26, 2011 the surgeon and author Dr. Atul Gawande addressed the graduating class of Harvard Medical School(1). He did not laud them for their years of hard work or salute the honor that was about to be bestowed upon them. He did not attempt to regale them with anecdotes of service to humanity from his own career. He talked instead, at length, about complexity. The medical advances of the past half-century have increased our ability to diagnose and treat disease in ways previously unimaginable. The price paid for these advances has been an exponential increase in the complexity of medical care. Unfortunately, western medicine has failed to develop systems of organizational management compatible with these exploding technological capabilities. This critical insight was what Dr. Gawande felt compelled to share with the Harvard graduates that day in May.


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The convocation speech defined the most desirable traits of a physician working within a less advanced medical system – autonomy, independence, and self-sufficiency. It then contrasted these characteristics with those required to cope with the complexity of our existing system – data driven, system minded, and team oriented. The evolving needs of the present-day healthcare system will drive physicians to adapt and incorporate these new skills. Pit crews, not cowboys, are what 21st century medicine requires. The driving concern over the past decade has been the safety and quality of care being provided by the U.S. healthcare system. Without appropriate planning, monitoring, and iterative improvements, a system of such complexity could never reliably deliver the miracles it promised. A similar understanding has now settled over the efficiency and effectiveness of the healthcare system. Money and resources are currently squandered not because of the system, but because in many instances there is no system. The previous article in this series described the accelerating transition from fee-for-service to bundled payments. All of the major payors have come to accept that this shift is an

Pennsylvania Society of Anesthesiologists Newsletter

essential precursor to both improving the quality of care and controlling overall costs. Once a healthcare system as a whole is held accountable for the desired end product - “health” - resources can be assigned appropriately to achieve the greatest output for a given level of input (ie; efficiency) and with the highest degree of reliability (ie., effectiveness). However, physicians too often see the move toward bundled payments as a zero-sum game: they believe that the size of the pie is fixed. Their objective during negotiations is simply to maintain the historical reimbursements provided for the same narrowly defined tasks described under the fee-for-service model. They compete against other healthcare system partners for the share of the revenue stream to be allotted to each of these defined tasks. This mindset represents a critical strategic error and necessarily leads to inexorably shrinking compensation. Each bundled or episodic payment is constructed to provide less overall revenue to the healthcare system than the most common historical fee-forservice components incorporated. Rather than struggling to divide each payment between the various specialties or individual practitioners, physicians should instead pivot to optimizing the use of resources. By decreasing the

length of hospital stay for each patient, focusing imaging studies and interventions on those most likely to benefit, and reducing delays and complications, the maximum number of patients can be served and bundled payments generated given the fixed assets available - beds, operating rooms, imaging equipment, physicians and nurses. This is the definition of efficiency. This same process also simultaneously ensures effectiveness. As both healthcare systems and patients assume increasing responsibility for the financial impact of healthcare decisions, the appetite for unproven or marginal value interventions evaporates. The demand for highly effective but less resource intense therapies grows. Those therapies that do not significantly impact patient outcome are discounted or dismissed entirely. How do physicians drive their systems towards this type of efficiency and effectiveness? By

learning to adapt to complexity. In “complex adaptive systems” large numbers of individual components interact in a constantly evolving pattern reflecting organizational learning. The hallmarks of such systems include (1) effective dissemination of information, leading to (2) a common situational awareness, allowing for (3) targeted deployment of resources, and (4) empowerment of frontline decision makers. Groups that function as complex adaptive systems establish clear organizational objectives and then push responsibility and accountability for resource deployment as far down the decision-making structure as is possible. Physicians should not, and will not, ever divorce themselves from the management of individual patients: reaching challenging diagnoses, navigating complex therapeutic pathways, balancing patients’ personal values with the available healthcare options. But the shift from fee-for-service to

bundled payments will also permit physicians to pursue heretofore neglected organizational goals which also serve patients’ greater interests. Imagine a physician-lead team investing (currently unbillable) time and effort perfecting prehabilitation programs for the highest risk surgical patients prior to admission because of the net savings realized from fewer post-operative complications and decreased length of hospital stay. Ponder the effect of multidisciplinary teams of specialists and primary care physicians meeting regularly to devote time to discussing the highest resource utilizers carrying various diagnoses – diabetes, kidney disease, heart failure, chronic pain. Consider the effect of a coordinated team approach to the most vexing patients rather than an endless rotation amongst subspecialists. Picture surgeons, anesthesiologists and internists continued on page 23

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Physician Anesthesiologist Jerome Adams, M.D. Named U.S. Surgeon General by Erin A. Sullivan, M.D., FASA District IX Director, ASA Board of Directors

Jerome Adams, M.D., was appointed U.S. Surgeon General of the United States on August 3, 2017. Dr. Adams is the first physician anesthesiologist to hold this important position. As the Surgeon General, colloquially known as the “nation’s doctor,” Dr. Adams will work to provide Americans with scientific information on improving their health and reducing their risk of illness and injury. The Office of the Surgeon General is part of the Office of the Assistant Secretary for Health in the U.S. Department of Health and Human Services. Dr. Adams has a passion for, and deep knowledge and experience of public health issues that accompanies his education, training and practice as a physician anesthesiologist. Physician anesthesiologists are leaders in patient safety and


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Dr. Adams will bring the same focus to support the health and wellbeing of Americans. Dr. Adams leaves his position as Indiana Health Commissioner, only the second African American to ever serve in that position. In that role, he oversaw the Public Health Protection and Laboratory Services, Health and Human Services, Health Care Quality and Regulatory, and Tobacco Prevention and Cessation Commissions. He was appointed to that position in 2014 by then Indiana Governor, Michael R. Pence. Dr. Adams is recognized as a leading expert in the substance abuse epidemic, and his swift and robust response to one of the largest HIV outbreaks in United States history helped avert a larger public health crisis amid the ongoing opioid abuse epidemic. He has testified before Congressional committees on the subject. Dr. Adams is a faculty member at Indiana University where he teaches residents and maintains a clinical focus on regional anesthesia and pain medicine. He works clinically at Eskenazi Hospital in Indianapolis, a level 1 trauma center, where he serves as chair of the Hospital Pharmacy

Pennsylvania Society of Anesthesiologists Newsletter

and Therapeutics Committee. He has authored several papers and book chapters, including chapters in “Anesthesia Student Survival Guide, A Case Based Approach,” and an editorial in the American Journal of Public Health titled, “Are Pain Management Questions in Patient Satisfaction Surveys Driving the Opioid Epidemic?” Dr. Adams completed his medical school training at Indiana University School of Medicine in Indianapolis. Prior to finishing medical school, he completed a master’s degree in public health at the University of California at Berkley, with a focus on chronic disease prevention. He completed his internship in internal medicine at St. Vincent’s Hospital in Indianapolis, and residency in anesthesiology at Indiana University. He is a Diplomate of the American Board of Anesthesiology, immediate past chair of the ASA Professional Diversity Committee, and served on ASA’s Health and Public Policy and Governmental Affairs Committees. The Pennsylvania Society of Anesthesiologists and the American Society of Anesthesiologists congratulate Dr. Adams on this outstanding achievement.

On the Other Side, When a Doctor Becomes the Patient by Lucy Guevara M.D.

What is a doctor? Technically speaking, a doctor is a person that dedicates his or her knowledge and skills to the prevention and treatment of diseases, while maintaining and even enhancing human health. The majority of physicians enter into the profession of medicine because they are committed to helping others. It is this mission-driven spirit and dedication that makes us grateful for the opportunity to care for others during a moment when they need it the most. The trust that patients place in their physicians is humbling. Every day is a new opportunity to learn, to grow, and the increasing ability to diagnose and treat is inspirational. The process of becoming a physician is not easy. It takes an extraordinary amount of hard work and a sense of dedication that is unique to the profession. Becoming a physician has long been lauded as an honor. As experts in biology, physiology, health, wellness and so many other subjects, some might view a physician as a human encyclopedia. However, referring to a physician as a walking, talking encyclopedia brings to mind the idea that most patients romanticize physicians in such a way as to be almost robotic in nature. Unfortunately, doctors are in fact, not robots and are as human as the patients they treat. It is hard to imagine with the long hours and the plethora of medical knowledge needed

to competently perform the job well, that a physician would ever deviate from the challenging schedules they maneuver on a daily basis with aplomb.

There are moments in which each physician finds him or herself with the reality that they are no longer in the role of a physician, but the tables have turned and they are faced with the reality of becoming a patient. Recently, I found myself in that very position. I was now playing the part of being a patient versus my regular role as a resident anesthesiologist. Fortunately, my role as patient presented in a more organized and orderly fashion. However, regardless of the non-emergent nature of my scheduled surgery, it still placed me in the position of feeling powerless. I could still control the date, location and surgeon, but I still felt that so much was out of my hands. On the morning of my procedure I found that knowing the process that would occur put me at a slight advantage, however, looking around at the other patients gathering in the waiting area with their loved ones, the anxiety was palpable. From the patient’s perspective,

their procedure is hopefully a once in a lifetime event -- one that could help alleviate all of their pain or cure their disease permanently. It is a day that could be the beginning or the end of much of their health issues. Yet as an anesthesiologist it is seen as another day at work. That does not diminish the importance of each patient, but it distances us from the very real feelings each patient is experiencing because of their specific case.

Lying in bed waiting for my IV to be placed, it was hard to not wear the hat of an anesthesiologist. I wanted to point out where I thought I had the best vein for a stellar IV. I did not initially share that I was an anesthesiologist, however it quickly became evident that I had a background in medicine and my role as patient reverted back to that of a physician. No, I did not have to hang my own drugs or fill out my own preoperative check sheet, but I was addressed continued on page 23

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Is Collaboration Necessary or Even Helpful? by Joseph F. Answine, M.D.

As a bill that could grant independent practice floats through the Pennsylvania legislature just a few votes from being sent to the Governor, we should consider the benefits and drawbacks of a collaborative agreement between nurse practitioners and physicians. Only a few years ago, as part of Governor Rendell’s Prescription for Pennsylvania, the current Pennsylvania collaborative agreement requirement was instituted, which is a very “loose” contract without geographic parameters. The physician does not have to be onsite, the meeting and chart review requirements are vaguely described as on “a regularly-scheduled basis” without a strict definition, and there is no maximum number of nurse practitioners a physician may collaborate with.


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The Pennsylvania Medical Society (PAMED) at the time, was disappointed to say the least with the “watered down” version of collaboration that was implemented. Yet, it is argued today by the nurse practitioners in the state that it is unnecessary based on studies demonstrating equality of care between them and their physician counterparts. It is reasonable to start with a breakdown of the educational differences between a primary care physician and nurse practitioner. Classically, a physician obtains a four-year undergraduate degree filled with mandatory education requirements especially in the sciences. Then, there is a fouryear medical education filled with didactic and clinical work. Lastly, the usual primary care residency requirement is at least three years of clinical care and research. Eleven years of training, therefore, is typical. A nurse practitioner most commonly has a four-year nursing education concentrating on the sciences and clinical care. Then, there is a requirement for a master’s degree which could take two to three years based on whether the education is full or part time. However, there are accelerated programs,

Pennsylvania Society of Anesthesiologists Newsletter

many online, that could grant a primary-care advanced practice in nursing master’s degree in as little as sixteen months. Six to seven years, however, is what is considered typical. Due to this discrepancy in education requirements between the two, I think it is fair to state that a common response from those individuals choosing a path to nurse practitioner over a medical degree and residency is that of “lifestyle”. The years dedicated to education and hours per day involved would be too burdensome along with the expected continued long hours of clinical work and education required to maintain skills and certification. It is appropriate, in my opinion, to make such life choices whichever path is decided upon. However, that dedication of hours, days and years should be taken into consideration where collaborative agreement is concerned. There are multiple studies, whether meta-analyses or individual studies, touting care equivalency between nurse practitioners and primary care physicians. Most studies, however, were observational, utilizing surveys to determine wellness and satisfaction with care. Furthermore, many of the clinical

endpoints such as blood pressure and glucose control are commonly protocol driven, and as I describe below, may not be the appropriate indicators for the need for a collaborative agreement. One of the most cited studies, using the most commonly utilized study design and endpoints, is from 2000 by Mary O. Mundinger, Dean Emerita of the of the Columbia School of Nursing, and colleagues entitled “Primary Care Outcomes in Patients Treated by Nurse Practitioners or Physicians: A Randomized Trial”. Patients in an urban environment were interviewed and physiologic test results were examined at six months after initial evaluation, and healthcare utilization data was recorded at six months and one year. There was no significant difference in health status and satisfaction based on the surveys, and no difference in glucose control or healthcare utilization. Diastolic blood pressures were lower under the care of the nurse practitioners (82 mm Hg vs. 85 mm Hg). What are possible limitations, of this (and many other studies)? Again, much is based on survey results. In this case, 90% of the population was only Spanish speaking and the results had to be then translated into English with possible variability in translating the responses. Healthcare utilization may be skewed due to ethnic norms and access as well. The tests used to determine outcome were narrowly focused on blood pressure, glycosylated hemoglobin, and peak flow rates for asthmatics. 3,397 patients were screened but only 1,316 were included in the study. Lastly, New York, where the study was held, is a state that requires a collaborative agreement and there were no obvious controls

for utilizing the collaborating physician in those patients cared for by the nurse practitioners.

What are the goals of a collaborative agreement? The goals are to allow an extension of patient care utilizing mid-level providers, but, still maintaining a level of easily attainable physician oversight, especially with more complex cases or those patients with illnesses not easily diagnosable. That being true, it is obvious why endpoints such as blood pressure or glycosylated hemoglobin are not appropriate to compare equality of care or the need for a collaborative agreement. Furthermore, utilizing the collaborating physician could and should decrease the need for physician specialist consultation along with the added healthcare expense.

What are the drawbacks of a collaborative agreement? Common complaints noted by nurse practitioners are unavailability of collaborating physicians based on geographic limitations, or limitations on the number of collaborative agreements that physicians can have, inability to contact the collaborating physician, and that collaboration in general, limits healthcare. In Pennsylvania, there are no geographical restrictions and there are no defined limits on the number of collaborating agreements a physician can have. Therefore, there should be no limitations on healthcare delivery even in the far rural areas that are in great need of primary care providers.

Furthermore, who is to say that a nurse practitioner will venture into those ‘out-of-the-way’ areas any more than physicians since there is no requirement for them to do so. The majority of nurse practitioners are actually found in urban areas. As for not being able to contact the collaborating physician; that can be rectified by the development of a cohesive relationship between the nurse practitioner and physician along with the placement of a successful contact mechanism. Also in Pennsylvania, so as not to limit healthcare delivery, meetings and case discussions on “a regularly-scheduled basis” are defined within each collaborative agreement and not by regulation or law. PAMED has been asked to negotiate and compromise in order to form an agreement between the two parties by Pennsylvania legislative leaders. However, any such “agreement” based on the current requirements would have to be the eventual independent practice after a prescribed number of hours served with a collaborator. Without enough (or any) wellperformed studies assuring that major acute illness leading to significant morbidity or mortality is avoided equally between nurse practitioners without a collaborative agreement and primary care physicians, and without evidence that healthcare accessibility is truly compromised due to the presence of a collaborative agreement in Pennsylvania; removing the collaborative agreement requirement for any reason or after any specified time adds no benefit to patient care in our Commonwealth.

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Special guest speaker, Representative Jim Christiana, at the Philadelphia Regional Meeting.

Dr. Josh Atkins welcoming members to the Philadelphia Regional meeting at the Union League Torresdale Golf Club.

From left: PSA members Dr. Bob Campbell and Dr. Rich O’Flynn with Representative Jim Christiana.


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Pennsylvania Society of Anesthesiologists Newsletter

Representative Christiana with Dr Thomas Mickler (UPenn Faculty).

PSA members enjoying the buffer dinner.


Eastern PA Regional Meeting Dinner

& PSA Vice President Dr. Tom Witkowski and PSA member Dr. David Paul.

Over 50 PSA members attended the PSA Eastern PA Regional Meeting and Dinner August 29 at the Union League Golf Club at Torresdale. Guest speaker, Representative James Christiana (R., Beaver) discussed his pending legislation for anesthesia administration in the PA General Assembly. He also discussed his candidacy for the U.S. Senate. PSA President-elect Dr. Richard Month discussed the recent PA Supreme Court decision about consents for surgical procedures and how this affects anesthesia care. This was followed by a lively discussion as to how this was being addressed at the various institutions.

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Insurance Prior Authorization Delays Harm Patients – Doctors Must Be Part of the Solution! by Jeff Wirick, Pennsylvania Medical Society Insurance companies say they use prior authorization to prevent physicians from prescribing too much medication or ordering too many tests. But physicians say the use of prior auth has grown out of control – and few stories illustrate it better than that of Joe Stanziano. Stanziano, who currently resides in Montgomery County (Pa.), owned a bakery in New Jersey. Ten years of carrying heavy bags of flour and working 18-hour days took a toll on his back. Stanziano had just undergone his fourth back surgery in five years and was taking pain medication to help with his recovery. Things were progressing well enough for Stanziano to begin taking a smaller dose of the pain medication – a process known as tapering that could eventually allow him to wean off the medication altogether. The problem is, Stanziano’s insurance company denied payment of the lower dosage that his neurologist prescribed. Hours turned into days and Stanziano continued to wait for his insurance company’s approval. When his current allotment of pain medicine ran out, the withdrawal symptoms began. “Cold sweats. Shaking. You don’t have control,” Stanziano described. This wasn’t a one-time mistake by his insurance company. Stanziano’s neurologist prescribed a lower dose of pain


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medication five times. It was denied five times for up to a week before it was approved.

period of time, and not be able to refill it, and have to go through what I went through.”

Prior Auths On The Rise As the delays grew Physicians have seen longer and withdrawals a dramatic rise in prior continued, Stanziano authorizations over the past few opted to buy the years for a variety of treatments and medications: medication out of • 86 percent of respondents to own pocket. Each a Medical Group Management pill cost $60. Association survey said that “One could imagine a reason for (denying it) if we’re increasing the medication, but in Joe’s case we were gradually decreasing the medication,” said Daniel Skubick, MD, Stanziano’s neurologist. “In spite of the fact that we were doing the right thing (by lowering his dosage) – getting him off opioids – pre-certs would still be coming.” Stanziano said he was never given a clear answer as to why his medication decrease required a prior authorization. “You could talk to two different people (at the insurance company) in the same day and get two different answers,” he said. “Explain to me the logic – why are you denying it when we were trying to reduce (the medication)? Does it make sense to you?” “Are you trying to cut costs, or are you trying to cut lives?” Stanziano continued. “I can understand trying to cut costs, but put them in my situation. Let them be on the medication for a certain

Pennsylvania Society of Anesthesiologists Newsletter

they experienced an increase in the number of prior authorizations over the past year. • Medical practices average 37 prior authorizations per week, per physician (taking up an average of 16 hours per physician), according to a survey from the American Medical Association. A few years ago, “if a narcotic that we’re prescribing was thought to be at a very high dose, you might have a pre-cert,” Dr. Skubick said. “But the prior auth would last 6-12 months and it might occur occasionally. Now, over the last few years or so, fueled by the opioid crisis, we’re running into pre-certs whenever a change is made to the medication.” The delays are proving costly to patients. Here are just two more examples: Pittsburgh’s Jeff Duncan waited eight months for approval on an in-lab sleep study that

he needed in order to receive treatment for his severe sleep disorder.

“What if I would have died with this?” he said. “Personally, I’m just irritated that the insurance companies have so much power over doctors trying to get their patients what they need.” Pittsburgh’s Kristen O’Toole experienced delays in getting an MRI for her back pain. The weeks’ long wait allowed her undiagnosed multiple sclerosis to progress, and she is now in a wheelchair. “If I had gotten the MRI earlier and started on the infusions, I really believe it could have kept some of these symptoms at bay,” O’Toole said. “Maybe I would have never ended up in a wheel chair.” “The doctor knows there’s a problem here,” O’Toole added. “There’s something going on. And how is he going to know before he gets the data from the MRI?” Dr. Skubick said his biggest frustration with the rise of prior authorizations is that it takes the clinical decision-making out of the hands of physicians. “I think it is incredible that the insurance company would think that a person who has practiced neurology for 35, 40 years doesn’t know more than somebody on the other end without seeing the patient,” he said. “I’ve never had a pre-cert denied for any diagnostic study when I’m able to talk to a colleague that is a neurologist.

“But I’m talking to people (at the insurance companies) who are not even doctors some of the time. And sometimes when you do get a doctor, you’re getting an internist or a gynecologist – what do they know about neurology? What do they know about the subtleties about whether an MRI is necessary?”

Physicians Must Be Part of the Solution Oncologist Rick Boulay, MD, wrote a recent blog for Kevin MD: “Most patients are unaware of this, but your physician is likely your biggest advocate when it comes to getting your care covered” from prior auth. Similarly, physicians need to step up to support new legislation in Pennsylvania that aims to decrease patient wait times from prior auth. House Bill 1293, introduced by Rep. Marguerite Quinn (R-Bucks), would: • Increasing transparency and consistency in prior authorization criteria • Establishing standards for and reducing the overuse of prior authorization • Lessen manual processes and enhance the electronic exchange of information • Developing a standard prior authorization form

Welcome New PSA Members! (Effective May 5, 2017 – Aug 9, 2017)

Travis Smith, Medical Student David Rodriguez, Medical Student Mabel Majekodunmi, Medical Student Loren Babirak, M.D. Pavan Malik, M.D.,MBA Michael Kitchens, Medical Student Shannon Haley, Medical Student Winston Hamilton, Medical Student Mustafa Hammudi, Medical Student Holly Turula, Medical Student Milap Rakholia, Medical Student Michael Desciak, Medical Student Akshat Gargya, M.D. Austin Sorchik, M.S. Serena Dasani, B.A. Zach Singer, B.S. Stephanie Lam, M.D. Michael Furdyna, Medical Student Sarthi Dalal, M.D. Rabiul Ryan, Medical Student Jonathan Deboer, D.O. Julie Sperling, R.N. Tarek Radwan, D.O.

The Pennsylvania Medical Society and its coalition of 50+ physician and patient advocacy organizations support HB 1293. But this legislation will only move with a strong grassroots effort from physicians, medical office personnel, and patients. See how you can get involved by going to the PAMED website, www.pamedsoc.org/PriorAuth.

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FASA Designation Program In May 2017, the American Society of Anesthesiologists launched the Fellow of the American Society of Anesthesiologists™ (FASA) designation program. The FASA designation is ASA’s highest acknowledgment that recognizes years of dedication to exceptional education, leadership and commitment to the specialty. ASA active members who meet specific qualifications and criteria are invited to apply for the FASA designation. Achieving the FASA designation recognizes you as a leader dedicated to excellence in the field of anesthesiology to your patients, your practice and your specialty. Participation in state component society leadership, education and advocacy opportunities helps qualify active members for this prestigious designation. Full details on eligibility, qualifications and the FASA application can be found at http://www.asahq.org/member-center/fasa

Coming Soon! We are pleased to announce the upcoming launch of

to PSA FASA Fellows:

PSA’s brand-new website!

Richard Month, M.D.,FASA Shailesh Patel, M.D.,FASA Andrew Herlich, M.D., FASA Andrew Boryan, M.D., FASA Erin Sullivan, M.D.,FASA Mark Shulkosky, M.D.,FASA David Metro, M.D., FASA Joseph F. Answine, M.D., FASA

Our goal with this new website is to provide more functionality and easier access to all things

Congratulations PSA’s

Shannon Grap, M.D. for being announced as one of PAMED’s 2017 Top Physicians under 40!

regarding PSA. Watch your email for the formal website go-live date!

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PRESIDENTS MESSAGE continued from page 1 Health System Leadership and “Leaders are visionaries with Organizational a poorly developed sense of Growth, and fear and no concept of the Business odds against them.” Development. Common -Robert Jarvis, MD values reflect physician led patient-centric care, continuous improvement, teamwork, leadership, education and professional citizenship.

Professional citizenship requires leadership. Active professional citizenship requires that members of a profession or society have responsibilities and ownership at

a higher level than their primary job. Active citizens take and give back. Always be a team player, pull your share of the load, lead by example, and stand up and do what is right. Our future depends upon internal transformation. There are too many takers and not enough givers. PSA will aim to promote increased professional citizenship through effective leadership and membership initiatives. Give your time, effort and if not, your money.

PSA - Active in Harrisburg There are now two pieces of legislation regarding balance billing; one in the House, as mentioned in our prior newsletter, and now in the Senate. We have met with representatives in the House, and the Senate Banking and Insurance Committee. It is

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Pennsylvania Society of Anesthesiologists Newsletter

likely that these bills will become active after resolution of the budget impasse. We will continue to oppose these bills by attending meetings with legislators. Once the time is appropriate, we will organize a media campaign through op-eds as well as meetings and interviews with journalists and editors. Talking points for all of us include: • Insurance coverage gaps are the actual major cause of increasing patient costs. • Proposed bills do not improve network adequacy. • Out-of-network payments should be determined by benchmarks such as FAIR Health rather than by insurers. When the bills move, we will ask you to provide grassroots support and leadership. Write to your legislator, enlist help of patients, friends and family and also recruit the support of local hospital administrators. I would like to conclude this last newsletter of my presidency by thanking all of you who actually read my articles and to PSA and its Board. The experience has been a collective effort which has made anything possible to be accomplished. I also would like to thank Libby Dietrich, Executive Director and Connie Benson Assistant Executive Director, who make the day-to-day operations of PSA work smoothly. Thank you and I hope to see you at ASA in Boston!!!!

REFORMATION OF THE U.S. continued from page 11 monitoring standardized pathways for outliers and focusing attention on those recurrent patterns that suggest preemptive actions might improve patient outcomes in the future. Bundled payments will unlock an era of the physician not only as biological scientist and healer, but also process engineer, data manager, quality director, logistics expert, and organizational leader. A sophisticated understanding of the complex systems in which healthcare now takes place will allow physicians to fully exploit the freedom associated with the retreat of fee-for-service reimbursements. However, a paradigm shift in the culture and values of medicine will be needed to permit this change. The Marlborough Man is riding away into the sunset and Dale Earnhardt Jr. is scheduled to give Grand Rounds next week.

The Committee on Practice Transformation: At the PSA Board of Directors meeting on March 18th, 2017 the Committee on Practice Transformation was formed and designated as a standing committee of the Society. This step was taken in recognition of the accelerating regulatory and economic forces presently reshaping healthcare. The charge to this new committee was to study the changing nature of the practice of anesthesiology in the Commonweath; to identify optimal adaptations in practice which could both meet evolving patient needs and enhance the position of the specialty; to study

the barriers to implementation of these adaptations in practice; and to serve as a catalyst for those local groups interested in hastening the incorporation of new paradigms at their institution(s). Over the coming months the committee will be reaching out to individual anesthesiologists across the state to gather information on innovative changes they have made to their systems of care – both those that have succeeded and those that have not. The next step will be to establish new channels which will allow members to share their experiences and learn from their colleagues. Current concepts under consideration include a designated area within the PSA website listing individual initiatives and descriptions of their implementation, local workshops around the state focused on overcoming hurdles to specific categories of change, and a clearinghouse of peers willing to mentor others through specific projects. A central tenet of the committee’s work will be to leverage the collective and ever-expanding experiences of the PSA membership. If you are interested in participating in this initiative or have suggestions to contribute, please do not hesitate to contact us at gordon. morewood@tuhs.temple.edu.

References (1) http://www.newyorker.com/news/ news-desk/cowboys-and-pit-crews

DOCTOR BECOMES PATIENT continued from page 13 differently. This shift in dynamic made me realize how difficult it is when a doctor becomes a patient. There are few studies that have explored the challenges that arise when the doctor becomes the patient. It is important to understand the inherent challenges faced when treating physicians. One quantitative study that focused on how physicians provide care to physician-patients examined some issues that arose, such as maintaining professional boundaries and adhering to guidelines. It concluded that further investigation was needed. With the inevitability of the physician becoming a patient, this is a perspective we as physicians should all consider. As physicians treat patients, we are afraid of making a life-changing mistake. This fear arises from the ingrained core principle of our profession: Premium non nocere or “first do no harm.” It is a principle applied to all patients and one that is exponentially increased as two physicians come together, especially when one of them is a patient. As physicians, we are every patient we treat and every patient represents a human life that should be valued and protected with the utmost of respect. It is my hope as physicians; we may always protect our most valued and lauded asset, our ability to care. May we always remember that our patients and their families have placed their most precious gift in our hands and may we always respect the frailty of our humanness.

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777 East Park Drive PO Box 8820 Harrisburg, PA 17105-8820