Central Line

Episode Number: 150

Episode Title: Hot Topics with Central Line Hosts

Recorded: December 2024

(SOUNDBITE OF MUSIC)

VOICE OVER:

Welcome to ASA’s Central Line, the official podcast series of the American Society of Anesthesiologists, edited by Dr. Adam Striker.

DR. ADAM STRIKER:

Welcome back to Central Line. I'm Dr. Adam Striker, your editor and host today. Today, to ring in the new year, we're going to do something a little different. I'm joined today by our guest host here on Central Line, Dr. Brooke Trainer. And she's here so the two of us can tackle some of the hot button issues facing anesthesiology. This is a new concept we're going to introduce here on Central Line. Every once in a while, have an episode where the two of us kind of recap or review an issue or two that are affecting anesthesiologists. Thought it would be an interesting way to have a dialogue and discuss some of these issues in a slightly different format than we typically do on the podcast. Brooke, welcome to the show.

DR. TRAINER:

Thank you, Adam, and really thank you for including me in this new initiative. I think this is a great idea.

DR. STRIKER:

Well, you know, usually as listeners who are familiar with the show know, we typically do an interview format and typically have an expert or somebody well versed in a topic and kind of pick their brain and listen to their insight and expertise on an issue. Um, I'm hoping that this maybe allows for a little bit more of a back and forth and discussion.

DR. TRAINER:

Yeah, this is unscripted, everyone. So full disclosure, no script here.

DR. STRIKER:

Yeah. That's right. Well, there were a number of issues we could choose, but I think the timely issue that we want to talk about is the Anthem Blue Cross Blue Shield decision to cap anesthesia payments at a certain time. And I'm sure most of our listeners are already familiar with this issue. But just as a brief overview, for those of you who may not be as familiar, Anthem had decided that in three states—New York, Missouri and In Connecticut—starting in 2025, they were going to tap anesthesia payments after a certain time for a given procedure. So if that procedure went longer, they would not reimburse the anesthesiologist for any further time. Currently, as you know, anesthesiologists get paid based on the type of procedure, the complicated nature of the patient, co-existing diseases, circumstances, and also time. And this, of course created a significant uproar in the anesthesiology community. Rightfully so. And most recently, in the last month or so, Anthem has decided that they are not going to proceed with that decision. And we're going to discuss maybe some of the reasons for that, but that's where we are now. So as far as we know, currently, that decision is not only on hold, has been made, hopefully, permanently that we will not be dealing with that issue anytime in the future. Um, so that's where we are now. We wanted to talk about not only the specific issue, but maybe the overall outlook of the insurance industry and how it affects anesthesiology and how the public perceives us.

DR. TRAINER:

Exactly. Yeah. And I really think we have to give a shout out to the ASA Grassroots efforts. I mean, this was a huge win. Uh, and, you know, it was a win for patients, you know, primarily. And, you know, they successfully overturned a huge major payor’s decision to cut payments. And that's not an easy task. Um, so first of all, big shout out to all the ASA Grassroots that went out towards this issue.

You know that it's an issue when, like your friends, who have nothing to do with the medical community, are like sending you text messages of the articles—the articles that you know very well, you know, because you're seeing them every day and you're, you know, impacted by them directly. But now your friends who have nothing to do with the medical community, also know about them. So, you know, this definitely made big news, I would say.

DR. STRIKER:

Yeah, it was about what would you say about two months when the membership found out that this decision was coming down before it was decided not to proceed with this? It was pretty quick.

DR. TRAINER:

Yeah, record turnaround. I did not expect that, honestly. I mean, when we when I heard that, I remember telling a surgeon that I was working with, you know, what’s going to happen, and we were making jokes about it. Surgeons are like, wait a second, wait a second. Is this for real or are they really seriously not going to pay you to stay for the entire procedure irregardless of what's going on? I'm like, no, this is this is what they've, you know, said they're going to they're going to stop paying us after a certain time frame. And they just couldn't believe it, you know? And then two months later, here we are. I was able to show them like look, rescinded. Can you believe it?

DR. STRIKER:

Yeah. Now why why do you think that it happened so quick?

DR. TRAINER:

I mean, I have to think that it had a lot to do with, you know, the CEO. And this is just my personal, you know, feeling, but, um, the CEO of United having, you know, that happened to him, um, so horrifically, I mean, tragically, but it just brought this to the limelight. And people, the fact that people had, like, no sympathy or very little sympathy for such a tragic, horrific death. I mean, it was it's kind of a frightening time to be living through that. That can happen and there be no remorse be, you know, almost lawlessness. But I, I have to think that somebody somewhere was a little nervous about this and said, you know what? Probably not good press. Probably not the time to be not advocating or looking like we're advocating for patients. Yeah.

DR. STRIKER:

And I know there was a certain ASA members that were teed up to do interviews on their local news the day it happened. Yeah. That were this the issue with the CEO getting, um, like, as you stated, horrifically, horrifically murdered and, um, and they were about ready to publicly try to, um, highlight this issue. And so the ASA was teed up to try to shine a light on this publicly. And then this happened. And I think it accelerated what what the public was aware. And once the news outlets were focusing on this potential, as this is a motivation for what what happened was, was blowback from the way insurance industry was conducting themselves. And then as that being a possible motive, I think they started looking for stories that that highlighted that kind of an issue. And this was just happened to be front and center.

DR. TRAINER:

Yeah, exactly. The timing was just, you know, could not have been more well timed as far as the controversy hitting the topic, you know, hitting the whole issue. And again, non-medical friends of mine, um, commenting on how insurance has also denied common medications that they, you know, need for their autoimmune disease and how the insurance is denied common procedures that you didn't even used to need prior authorizations and things like this. So now they're denying care and then they're denying payments. And meanwhile, you know, they're racking up the greatest revenue that, you know, they've seen in decades with their returns on investment. And, you know, you start to think like healthcare is one sector in our economy that should not be about becoming rich. If you want to be a millionaire, you should not go into healthcare. You know, that's my feeling. Um, I don't know if I'm alone in that, but, you know, I just think that this is a sector that we should be focusing on patients on doing the right thing. And yes, we are hardworking people. We deserve to be reimbursed for that. Um, I mean, truth be told, we could have gone into any area of practice. Like we could have become lawyers charging, I don't know, my lawyer charged $500 an hour, I think, for our recent lawsuit that we had. Um, but, you know, I think that we could have done anything we wanted to. And we chose to go into medicine as capable, intelligent, diligent stewards of of, you know, wanting to do the right thing. And we deserve to be reimbursed. Should we be millionaires? Are we millionaires? No. I mean, this is a fallacy, you know?

DR. STRIKER:

Well, there's so much to to tackle here. First off, I agree completely. Nobody should be going into healthcare now to become rich. And we all practice with individuals all the way from local administrators all the way down to anybody that's just walking the halls in our local organization. And I don't know anybody that is in, in this business to to get wealthy. And they're there because they want to be there. So the issue of, of doctors somehow being the driver, not even doctors, any clinician, but doctors specifically, being the driver of of health care expenditures, being out of out of whack. Is it just it's such a fallacy.

DR. TRAINER:

Yeah, it's totally misunderstood as well. And I think it might be worth, um, I think it might be kind of worth sort of laying out how payment actually works for us because that I feel like, is very misunderstood. Um, and I think it's helpful for even the general public to understand that, you know, we really don't even know oftentimes, like what we're getting reimbursed. Right? Because it's not usually me, the doctor, the person who's like administering the anesthesia, who's contracting with payers, for example. Right. I'm not the one that's sitting there negotiating with the payor to say I need to be paid this right. It's usually the hospitals or the the owners of these groups. Um, you know, big anesthesia groups. And you kind of get what you get with these contracts. And so, you know, Anthem contracts with the hospital, contracts with the anesthesia group and says, we're going to reimburse you this. I, as the lay anesthesiologist, don't necessarily know what that reimbursement is. If a patient were to ask me, what is my insurance paying you? I have no idea. You know, but then does that equate into, you know, you have productivity pressure because you have to perform and you have to do X number of cases and X number of time to justify the salary that this hospital decided to give you, probably based off that contract. Yes. I have tremendous production pressure. Right. Turnover time.

DR. STRIKER:

Yep, yep.

DR. TRAINER:

You know, we are always being monitored, regulated and pushed to go faster to supervise, more to… And that's not because they're looking at patient safety. That's not because they're looking at like what's best for the patient all the time. It's because they're looking at, you know, the return on investment, right. The payer is going to pay this. We're going to, the hospital is going to get this reimbursement, and we're going to have to pay this salary to this anesthesiologist. So we need them to see three patients an hour, four patients, and, you know, whatever it is. Um, and I don't even know that that is completely what comes into play when deciding on even ratios. You know, in when we're supervising, um, CRNAs or supervising, you know, AAs or residents, I'm not sure that anybody has really said you need to supervise this many people for this payment to make sense or for us to be able to afford you. Um, so the payment is really complicated. And that's not even accounting for, like, all the OR time and the technicians they have to pay and the administrators that have to process the prior offs, and the administrators that have to complete all the paperwork for the patient to even have this surgery today, and all the equipment that goes into what we use to anesthetize. So much goes into it that payers aren't even reimbursing us for. Right. That's coming out of our bottom dollar. So I don't think, again, we don't go into medicine because we think we're going to be in the 1%.

DR. STRIKER:

Right. Right, exactly. Well, and I think most anesthesiologists, I dare say most physicians nowadays, probably don't even understand how they're getting paid. I mean, they understand they're getting paid from either their practice or the organization they're working for. But but after that, the complexity is huge. And for I mean, we can't even do it justice here in this short podcast on all the moving parts, but most physicians even probably wouldn't be able to articulate all of the nuances. And, you know, in general, we understand how insurance reimbursed for anesthesiology services, but the vast majority of practitioners out there are going in there doing their job. All they know is they get they get a salary to come in and do the job and they do their best. That's right, and that's it.

DR. TRAINER:

And that’s why. I really I don't want to cut you off, but that this advocacy where all of us anesthesiologists came out to advocate for this, it wasn't for us, it was for our patients. Because, again, we don't actually see directly the payment from the payer. Right? The hospital does. And then the hospital pays salaries or the group does. And, you know, so I'm just, I'm generalizing a lot. But for the vast majority of us, you know, who are, you know, hospital based, you know, ASC based or big groups, you know, based. That's a lot, majority of anesthesiologists out there. Um, we were advocating because we knew that if payers stopped paying, that patients would end up footing the bill or our group's hospitals would go out of network with these payers. Right. They would just stop contracting with them, go out of network with them, say, we're not going to take your patients anymore. And so then now these patients are left without care, right? They're left without care or they're left with a bill for that care for that out-of-network bill or that, you know, remaining cost. And so that's why we went to bat for this. And so I really you know, I did hear a lot of media out there talking about how big anesthesiologists are just fighting for their reimbursement. It's really not the case for most of us.

DR. STRIKER:

Well, and the reality is that, probably maybe not within the physician community, but but the lay public, a misunderstanding of what would have happened based on articles that I've read or snippets from media outlets that I have read. There was this thought out there that somehow a surgery or a procedure is going to stop at a certain time if we are not getting paid for a procedure that's going to go longer than whatever the insurance company deems as appropriate. That would never have been the case. Nobody, nobody would stop a procedure or rush through it because it has to be done by 9:30. I think we in the in the anesthesia community recognized is the problem is that people are simply not going to schedule or do these procedures when they know they're not going to get paid for it. It's not. Nobody is going to be on the table and be subjected to a rushed surgery. So when you, you're right, when you talk about, you know, anesthesiologists doing this for the patients, I think we we recognize the reality of what what would ultimately happen with with the access to care.

DR. TRAINER:

Mhm. Yeah. I mean it's, I like to use the analogy that anesthesiology is a lot like flying a plane. Right? And the anesthesiologists are the pilots. And just like if the airlines decided that they were no longer going to pay the pilots after a certain time frame of this flight, like they, you know, calculate the time frame from, you know, DC to San Francisco and God forbid, there's weather or, you know, um, a detour or you got to fly a different route path that was, you know, unexpected. So it takes you a little bit longer. You know, God forbid that the airlines told the pilots that, sorry, no matter what happens, whether encountered or, you know, you got to go a different route. We're only going to pay you for what the route should have taken or what the route, you know, in most cases would have taken. What's the likelihood that a pilot would be okay with that? No, they would go on strike. They would shut down the flights to strike and unionize and say, that's not right, because we can't predict the weather. We're not the ones determining our flight path. The air traffic controllers are doing that. Just like for us. The surgeons are the one controlling the surgery. We're not controlling the surgery. We're just on the flight path that we're told to take. You know, like, we are no different than a pilot who's supposed to go from point A to point B safely take you off, safely land you, get you there, you know, comfortably and safely. Um, but we have no control over all of the factors that could happen in between. So it's really unfair. But we can't unionize and we can't go on strike. Right?

DR. STRIKER:

Right. And I'll even I'll even expand a little upon your analogy, because I think it's an excellent analogy. With what we do, it's not simply, you know, cruising and handling emergencies. We have to do that. That's a part of the job. But dealing with the complexities of each patient necessitates a completely different flight plan each and every time to stay out of that trouble. You know, it's like the idea you have to fly and there's a storm or there's bad conditions, but you have to get to your destination. You have got to figure out a way around it. It's something like that for each patient, though, each patient is different. Each patient has complexities. Each situation is different. And so even with anesthesiologists, do is layered on top of taking off and landing safely. There is it's it's staying out of trouble and then having to deal with trouble once it arises, which oftentimes can happen.

DR. TRAINER:

That's right. I've used this analogy actually in some talks before, you know, when Sully landed the plane in the Hudson River, right? I mean, what if the airline said, well, that's not where you are supposed to go, so we're not going to pay you for that day. That’s not in the flight plan. And so you're not going to get paid for that. You know, I mean, you could arbitrarily see how this could get worse if we allowed these insurance companies to go unchecked. Right. I mean, what could be the ultimate that they say, well, you know, this complication happened. So we're not we're just not going to pay for the whole case. I mean, if you don't stand up for it now, how far are you going to let it go before they keep pushing, keep pushing and keep testing? It's like a toddler. You know, they don't have boundaries.

DR. STRIKER:

It's, you know, it's so true. It does feel like that with all the issues. Regulatory, um, technological production, pressure wise, that anesthesiologists have to deal with on a daily basis, the insurance companies starting to parse out these little snippets of where and when and how you're going to get paid. It's it's so, it really strikes a chord, I think, more than just the general milieu of healthcare costs going up or reimbursements in general across the board. It does feel like an example of insurance companies testing how, right, as you said it…

DR. TRAINOR:

What they can get away.

DR. STRIKER:

What they can get away with. I, like we talked at the beginning about reasons for why this accelerated and that I really think once this got to the public spotlight, I think the same thing would have happened. It's just that the the unfortunate event with United's CEO, I think, accelerated the public's perception of the issue. But I do think the fact that they rescinded the decision so quickly, the PR milieu was, was just not good for something like this at, you know, in the last few weeks, however, um, the fact that it was rescinded so quick, I think it just underscores how unneeded this decision was. And, and I think lends more evidence to what you had said, that they're testing the boundaries.

DR. TRAINER:

They're just testing the boundaries, seeing what they can get away with. Like, I mean, I don't know if you recall what happened in Massachusetts with the colonoscopy, uh, anesthesia policies. You know, in Massachusetts, they said that if and correct me if I'm wrong, but they said if you're of a certain age, if you're younger than that age, then you are not going to get like prior authorization or qualify for anesthesia that you have to get just conscious sedation. So you have to be semi awake for your colonoscopy. And if you think about it, most young people that are getting colonoscopies, because that's not normal are with a condition, right, with some type of condition, Crohn's disease, ulcerative colitis, or God forbid, cancer. You know, that age, that they need frequent colonoscopies. And so you have already the trauma of having a chronic, debilitating disease at a young age that requires these advanced procedures frequently. And then you're you're going to traumatize them, you know, like PTSD traumatize them every time they get this procedure, you know, and not let them have anesthesia. They have to be awake or semi awake for these. It's so unfair. And that's just some blanket policy that you as a payer, you have no, there's no medical rationale whatsoever. It's just let me see if I can sling this mud and see if it sticks.

DR. STRIKER:

Yeah and, well, and they also with their decision recently to stop paying for physical status modifiers is another example. Yeah. We're not going to you know what patients complex that just goes with the territory. You know instead of you have a healthy patient for an elective surgery or you have a sick, critically ill patient for a major, major operation.

DR. TRAINER:

And yeah, you just get paid the same no matter what. And really, again, us advocating to reverse that is advocating for the patient. Right. Because what's going to happen natural selection. We're just going to naturally select for the easier healthier patients because they're going to get reimbursed. And I'm not saying we as anesthesiologists, I'm saying like the hospital systems who are the, you know, who do look at the bottom dollar, you know, the venture capitalists who own a lot of these groups. Your fate is in the hands of these people who do have the bottom dollar as their primary endpoint. And so what they're going to do is they're just going to say we don't do ASA threes and fours anymore here at this ASC or this surgery or this hospital or whatever, you know.

DR. STRIKER:

Yep.

DR. TRAINER:

And that patient, that vulnerable patient is the one who suffers. And that's not fair. That's not fair. So yeah I think that um this has definitely, I think at least shed light on the fact that some of these policies or fixes in reimbursement are really subjective and arbitrary, and they're not based on medical necessity. They're not based on anything other than let's see how else we can save our money. You know, our investors. And this makes me want to talk also about the Medicare Advantage plans. Um, that that that system as well. But but just to close this loop, um, we should not be putting health care dollars in the hands of investors, right? Like this is a patient on the other end of this who has real consequences when we focus primarily on investing and making money off of this.

DR. STRIKER:

Right.

DR. TRAINER:

And that's the same thing I want to say about these med advantage plans. So there's this, you know, new initiative over the I don't know, the time frame, but it's been five, maybe ten years where they're letting big payors, private payers, insurance companies like Anthem and Aetna manage--so it's the managed Medicare plans--manage Medicare. And this is horrible for patients, because now what they're faced with is a ton of prior authorizations, lower reimbursement to the providers, and in the end, the Medicare dollars, which are taxpayer dollars, those dollars end up in the hands and benefiting and lining the pockets of these insurance companies. Again, taxpayer dollars should never be used to make money, you know, or invest and make money off of. So my understanding is the Medicare reimburses the, you know, episodic payment or whatever it is for that patient in a lump sum and gives that to, let's say, you know, Anthem. And then Anthem decides how they're going to divvy that up. You know, if they're going to divvy it up, you know, you can have, you know, this authorization for this, you know, my family owns a home health care agency, too. Little fun fact. So I learned a lot about how home health care works through my family owning that. Um, and I know for a fact that, you know, Medicare used to be the great payer for those patients, for the elderly, you know, getting care. They didn't have to have a prior authorization for that. And it was actually a decent payer. Now, nobody wants to take managed Medicare because they're one of the lowest payers. And all the remaining Medicare dollars go back to the payer, go back to the insurance company who's managing them. And so now you see all these advertisements in the journals on billboards begging, you know, patients to sign up for managed Medicare when they could just get straight Medicare, but they'll they'll pay them like $20 a month for groceries if you sign up for Managed Medicare. And then they you see the articles come out after that, that show how Anthem made, I think, $1.1 billion off of Medicare last year, managing Medicare. You know, they talk about how much they saved, but then they talk about how much they made. How is it that we're allowing taxpayer dollars to be invested into payers? That should go straight to the provider, straight to the patient, or don't tax the tax payer, you know, it shouldn't be used to make money off of it. It should be budget neutral. So I don't understand these managed Medicare and how we got to where we are now and how our government has allowed this to happen either. That's probably a whole other discussion.

DR. STRIKER:

Yeah. Listen, I think what you, what you just articulate it, I think is just a nice illustration of just how complicated this industry has become. Whatever the solution is, if there is a solution it that it it's going to need to kind of get back to the basics, whereas the people providing care are the ones getting reimbursed. And whether it's an insurance company or a single payer system or whatever you want to call it, um, that that is the cost is going directly to the, the care of those patients. And I, I am not an expert on, you know, insurance industries. I mean, I'm.

DR. TRAINER:

Neither am I like.

DR. STRIKER:

I'm an anesthesiologist, but, um, and so I, you know, there is a role, whether it's an insurance company or government or somebody to, you know, help defray the cost of medical care for for every individual in this country. There is a role for that. But obviously, these things have become so complicated that you can't even make heads or tails of some of these systems. They're just it's they're just such, such large entities to even provide a, you know, a really good analysis. Which actually brings me to the next facet of this topic, that I want to talk about, which is how the media covers these issues or how the public perceives these issues, because it's so complicated and because, depending on what outlet you choose to get your information from, you can have a much different opinion from somebody else who gets their information from some other outlet on how this industry functions or or how you think it should function. I think most of the listeners are probably familiar with a Vox article that had come out on the heels of this decision, actually criticizing the insurance companies for rolling back the decision that we're talking about. Anthem's decision, when they they decided to roll back the decision to not reimburse anesthesiologists after a certain time. This article actually said the insurance companies made a mistake by rolling that decision back, and that, of course, I'm sure most of our listeners are familiar with that article. We don't have to rehash the article.

DR. TRAINER: Yeah I think that article, it just seems so biased, you know.

DR. STRIKER:

The conclusion of the article was so definitive on such a specific issue, amidst the sea of complexities that we have been talking about, that it was. To me, it was an odd article. That's all. I just it's so I don't know if it's motivated or if it was simply cherry picking certain pieces of data or certain decisions to make a point. I don't I don't know for sure, but it was it was just strange.

DR. TRAINER:

My nine year old would call that sus. That was very sus.

DR. STRIKER:

Yeah it was. And there was certainly a lot of, uh, a lot of strong opinions from anesthesiologists about that.

DR. TRAINER:

And patients, I would say, because even patients right now are angry with payers. And so to have an article come out that actually is on the side of payers is, you know, kind of the anti-hero right now.

DR. STRIKER:

Right.

DR. TRAINER:

Um, but because it's so complex, it's like you said, it's very hard to draw the definitive conclusion and say, this is how you should have done it, and this is why you should have done it this way. Without thoroughly understanding all that really goes into the system. Um, and so my suggestion is, you know, I do think that anesthesiologists can do a better job in improving that awareness of what it is that we do and how it is that we play a vital role in, you know, at least their surgical care. Um, and that way they understand exactly what it is that goes into what we're getting paid for. Right. Um, we're not just pushing autopilot at cruising altitude, right? There's a lot of turbulence, and there's a lot of, you know, things we have to prepare for for a landing and takeoff and, you know, the destination, the type of aircraft. Everything matters. And so, just like, you know, we don't thoroughly understand how a pilot runs that aircraft and that aircraft's extremely technical and takes lots of training and hours of dedication. Same with our our career and our job and taking care of patients. Um, so helping patients understand what it is that we do, I think can help, at least in the advocacy arena, when things like this happen, when payers make these arbitrary subjective decisions, you know that we have this coalition of supporters fighting for a common cause.

DR. STRIKER:

Yeah. The, you know, the ASA, the communications committee that we both have are part of, you know, makes that its uh, its mission. And it's, it's a tough thing to do. Anesthesiology is a, uh, I think most of the public can spout off a sentence or two about an anesthesiologist does, because it's in the name. Oh, they put you to sleep and wake you up. The problem, and I think this is the problem anesthesiologists fight when it comes to the the image, is not that it's not a good image. I was actually encouraged by a lot of the blowback that article received and blowback about the Anthem decision, whether, you know, reading comments in the New York Times or the Washington Post, that I think most of the public values what an anesthesiologist does. They understand the importance of of medical care while while you’re asleep having an operation. So I don't want to, you know, overstate the issue. But I do think the struggle is for anesthesiologists because it's a little bit mysterious, it's not simply about putting a patient to sleep and waking them up. It's being your patient's doctor. It's caring for all the complicated medical systems while they're asleep. And trying to message that is not easy. And I think we are, this phrase has been used, I'm sure, in a number of realms, we’re victims of our own success. You know, our predecessors have done such good work over the years, improving the safety profile of anesthesia care, and have made it such that we can do more and more complicated operations because the anesthetic care of individuals, from simple to complex medical issues, can be provided for safely. And I think because of that, I think that's part of the issue now, not only the public's perception, but then you get articles like the one we alluded to where it's become so routine, or we make it look so routine as a specialty, that you can start now taking it for granted. It's just like going back to your pilot analogy. Most, you know, fortunately airline travel is, for the most par,t very safe, statistically. And and then you start to focus on maybe more of the minutia because we're all benefiting from the overall safety profile and success rate.

DR. TRAINER:

That's exactly right. And I think again, going back to, you know, Sullie landing on the Hudson, that was a remarkable thing. But I'll just tell you a funny story. So my grandfather was a Navy pilot, and then he flew for American Trans Air for like, I don't know, 40 years. And before the airline got bought out and he retired, um, and I called him when, you know, this happened, I said, isn't that remarkable? Can you believe that? He did that? And he said, no, Brooke, this is exactly what he was supposed to do. He was trained to do that. And his view was if he hadn't landed it safely, that would have been, you know, him incompetent. But because he's a competent pilot, because he's well trained, because he's done years of experience, that's exactly what he was supposed to do. And that's what we do, you know, day in and day out. Deal, you know, with these patients who are very complicated, I mean. Right? Cardiac anomalies. They're born with heart defects, and they're living to have babies. You know, I mean, these are remarkable advancements that are leading us to do more and more complicated cases. And we are expected to safely land that plane under any kind of complication. Turbulence. Weather. Flock of birds. Whatever. Um, and that's what we're expected to do.

DR. STRIKER:

Yeah. Absolutely. The routine is only routine because individuals have spent years and years training and practicing and preparing and studying and and you just you that…

DR. TRAINER:

That's why we make it look easy.

DR. STRIKER:

Yeah, yeah, yeah.

DR. TRAINER:

I mean, that's that's all, that's the reason. Yeah. And, you know, and I think that this is a great conversation. I mean, I really think that this, these conversations we need to be having, you know, with our friends, with our patients, with our surgeons, you know, with our CEO executives. You know, I wish we could have more of them with our payers. Unfortunately, you know, they sit too high up there in the clouds.

DR. STRIKER:

Yeah, that's… Well, as long as we're discussing this, I do want to get your thoughts on the piece of legislation out there in response to the Anthem decision. And I'm going to pull it up here.

DR. TRAINER:

Anesthesia for All Act. Yes.

DR. STRIKER:

Sponsored by, I believe, Representative Torres. Is that right? Out of New York?

DR. TRAINER:

Ritchie Torres. Mhm.

DR. STRIKER:

And basically it's, to sum up, it prohibits insurance companies from doing what they were trying to do, if I'm not mistaken.

DR. TRAINER:

Yes that's right. So it prohibits them from time capping it like they did. Um, it specifically about time capping anesthesia reimbursement so they can't put a time limit on there. You know, and the thing that I think is funny is, you ever, you know, see those weird laws like, um, you know, I don't know, like, I can't think of a weird law right now, but, you know, you think. How in the hell did they come up with that law? Um, like, somebody must have done something that led to them to have to come up with that law. Well, this is one of them.

DR. STRIKER:

That's a good point, right?

DR. TRAINER:

Like, do you think, why do we need a law to regulate this? Right. It's because they're so out of out of touch. They're so unchecked.

DR. STRIKER:

Yeah. Here, I pulled up the text of the bill as it currently reads, or at least this is what's published so far. A group health plan and a health insurance issuer offering group or individual health insurance coverage may not impose arbitrary time caps on reimbursement for anesthesia services provided during medically necessary procedures. Reimbursement for anesthesia services shall be determined based on medical necessity, as assessed by the attending anesthesiologist or licensed anesthesia provider. Group health plan and a health insurance issuer offering group or individual health insurance coverage are prohibited from denying payment for anesthesia services solely because the duration of care exceeded a preset time limit. And then it goes on to talk another section about Medicaid. But that's the gist of it. At least that's not the full text, but those are a couple of key passages.

DR. TRAINER:

I would like to see this expanded actually to say that medical necessity, for example, like I heard you read something about like the the medical necessity of the anesthesia will be determined by the anesthesiologist performing the anesthetic. Right. That is common sense. But that is not how prior authorization and the determination of medical necessity actually works. So, you know, right now it's not the expert that's determining whether or not you're allowed to have this procedure or allowed to have this drug. It's the payer.

DR. STRIKER:

But this is exactly the the problem with. And I'm not I'm not sure about pieces of legislation because I feel like it's it's probably not the ideal way to handle it because I feel like I don't know that it adequately, as you pointed out, describes the true system. And then I don't know how it creates more problems.

DR. TRAINER:

Right.

DR. STRIKER:

That we end up dealing with? Um, it's.

DR. TRAINER:

We shouldn't need law.

DR. STRIKER:

Exactly, exactly. It's one of these things that. And I don't know, I don't I don't know if something like this would be better or not. Um, you know, because I do feel like once something's on the books, then you have less, less latitude to deal with, more complicated issues. But, um, you're right. We shouldn't need a law. This should be fairly sensible.

DR. TRAINER:

But sometimes, again, you know, when you're dealing with toddlers with no boundaries, you got to set up rules.

DR. STRIKER:

Yeah. And I mean, listen, I think the. Whether it's this law or any law, I think it's probably good that there, there is now some oversight or some pushback on perhaps testing those boundaries in some fashion and we'll see. I don't know that this this I mean, this was just introduced obviously. So I don't know how um…

DR. TRAINER:

Yeah, we'll see where it goes. I'm very interested in you know, I think again, this is another plug for our listeners to get out there, to speak on these issues. You know, our communications team, they're helping our lobbyists. They're helping our key stakeholders get out there and talk to these people, um, and make contacts and build relationships and, you know, encouraging their support.

DR. STRIKER:

So I think, um, the advocacy piece is important, and there's certainly multiple ways to advocate on behalf of your patients and your profession. And, uh, nobody likes dealing with politics. It's unfortunately, it's a reality of the system we have. But if you're an individual who really shies away from that. Then, as you stated, at least support individuals that you do know are a little more adept, or that you support or supporting those individuals who will then advocate on issues that you're in favor of. It is important. So whether that's monetarily, whether it's donating time, um, whether it's you yourself maybe making a trip to or a visit to talking with the local legislator, anybody. Um, there's a lot of ways that that you can support advocacy. Obviously, I think certainly every anesthesiologist should be supporting the the ASA PAC, because I do think it's an important vehicle to communicate our issues to legislators who are making these laws.

DR. TRAINER:

Well, guess who has more lobbyists than we do, you know, Anthem Blue Cross Blue Shield.

DR. STRIKER:

Yeah, that's a big that's a big organization. Yes it … well stated. Well, I think it's a good way to close that because I do think the ASA does a it does do a great job. Listen, we're doing a podcast that's the ASA podcast. So I mean, the fact that we're involved shows that we believe in the society, but the society itself is made up of anesthesiologists, and it's not a vague entity. It's made up of practicing anesthesiologists, colleagues of ours, but we believe in it. In reality, I do think they do a great job of advocating on behalf of patients and anesthesiology issues. And this issue in particular, they they were not only on top of they did they did a great job advocating.

DR. TRAINER:

Oh yeah. This is a slam dunk.Great job.

DR. STRIKER:

Um, well, we should probably wrap it up. Anything else you want to add?

DR. TRAINER:

No, this is, I think, a, um, interesting way to, to do podcasts. Um, I will say I was a little nervous, you know, not having a script to kind of go off of, but, you know, it's so easy talking with you, Adam. So this is really nice. Thank you so much.

DR. STRIKER:

Yeah, I enjoyed the conversation. Thank you very much. Hopefully we get to do this again because I think it's a, it's a nice way to sort of rehash some bigger issues that we have to deal with. So thank you for joining us. And thank you for all your stories and your insight. And, um, it's it's always a pleasure to talk to you, Brooke.

DR. TRAINER:

Same, same.

DR. STRIKER:

Uh, to our listeners, thanks for joining us on this episode of Central Line. Uh, please tune in again next time, and we will be back to our more conventional format on the next episode.

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VOICE OVER:

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