From the President

By Kenneth Y. Pauker, M.D., CSA President

Address of the President-elect to the CSA House of Delegates, May 2011

Salutations & Greetings to all,

We are honored, at the CSA House of Delegates' Annual Meeting today, by a veritable panoply of distinguished visitors:

• Steve Barker of AZ, Leffingwell Lecturer, Chair at Univ. of AZ;
  
• Jerry Cohen of FLA, ASA President-elect;
  
• Bob Johnstone of WV, ASA VP Professional Affairs and candidate for ASA 1st VP;
  
• Jim Grant of MI, ASA Treasurer;
  
• John Abenstein of MN, ASA Speaker;
  
• The CSA's own Linda Mason of CA, ASA Asst Secretary;
  
• Jane Fitch of OK, Chair at Univ of OK, Chair, ASA Govt Affairs, candidate for ASA 1st VP;
• Kathy O'Leary of NY, Pres of NYSSA;
  
• Dan Cole of AZ, Past President of the CSA and Chair of the 2011 ASA Annual Meeting in Chicago;
• John Thorner of ILL, ASA Executive VP in Park Ridge.

That the CSA has attracted such a turnout from ASA leaders from all over the country speaks volumes about how important CSA ideas and participation has become to the ASA. Let's thank each of them for coming to San Jose to be with us.

Now, I'd like to acknowledge those who are most responsible for my standing here today. When I began my involvement with the CSA, I just wanted to participate in the work and have a chance to hang out with the stimulating characters I have come to know at the CSA and ASA, but these folk wanted more from me, and, after a while, bit by bit, I came to the hopeful realization that my ascending the leadership track would be good for the CSA and a stimulating journey for me as well. Steve Goldfien took me aside soon after I first attended a CSA BOD meeting and told me to read Sturgis, to study Krause's Death of the Guilds: Professions, States, and the Advance of Capitalism, 1930 to the Present, and to join the CMA if ever I wanted to become a CSA leader. He challenged me with his ideas, and he involved me in the ASA Committee on Anesthesiologist Assistant Education and Practice, which he chaired. Steve Jackson nurtured my writing and craftily suggested topics for Bulletin articles, subjects with meat on the bone, the chewing of which plumped up my comfort with practice affairs and medical politics. I came to appreciate that taking on the task of elucidating complex issues is a process of discovery, and that you wind up understanding them much more deeply, often appreciating hidden subtleties, than just reading about them or even studying them, and that writing makes you a more articulate speaker. Dan Cole made me believe that my passion and my probing approach to issues were talents that should be deployed in the service of elucidating gnarly issues confronting both the CSA and ASA. Jim Grant and I just basically bonded years ago. He wrapped me in his warm optimism and clear thinking, encouraged me, and pushed me onward.

And then, there is my Debbie, my beautiful young wife of 30 years, my city girl from Pittsburgh, the mother of my remarkable daughter and son, my confidant and friend. She has her reservations about sharing me with the CSA, but she knows my heart in this and every matter, and she loves me enough to be here today to demonstrate her support. We all know that one year is really just a flash in time. Thank you in advance, Debbie. I love you.

As I look out upon the faces in this Grand Ballroom, I am proud and honored by the confidence you are showing in my ability to lead this venerable society during this tumultuous time in the history of American Medicine.

So, here am I, a community anesthesiologist, a reformed internist, on this path less traveled. We all are beset by distracting external considerations that conspire to have us forget what past ASA President Roger Litwiler declared so unequivocally just a few years back, "It's all about the patient, because we have no other reason to exist!"

Common wisdom is that "it takes a village," and we here together are that village. Indeed, it surely will take all of us, playing off each other; sharing perspectives, ideas, and strengths; strategizing; and then acting together, testing perhaps what some might declare to be the legal limits of collective action, to do what needs be done to save our patients and our profession from the "charlatans, poachers, and quacks" who are swirling around us, probing for weaknesses, wrapping themselves in the cloak of the FTC, trumpeting about "practicing to the full extent of their licenses," and hoping to invoke the ill-advised antidiscrimination clauses in PPACA.

The spectrum of issues arrayed before us as anesthesiologists practicing in California is broad and deep, both unique to our state, and also as local iterations of a national agenda. Most everyone is this room has heard of them, but some folks have paid less attention. Please refer to the written version of this speech - in the Bulletin and on our website - for my list of 29 important topics on the table for national, state, or internal CSA action. My plan is to post at www.csahq.org a continually updated prioritized list of key issues, and soon to make available an opportunity for each and every CSA member to comment upon each item, and even to add to the list. For now, I will focus on just five particularly critical issues that will demand attention during my Presidential term, and give you the flavor of how I mean to move you who are the CSA to try to address them.

1. The nurse anesthetist opt-out is a manifestation of an insidious expansion of the scope of practice by advanced practice nurses. The rationale is that this maneuver intends to enhance "access to care," but it seems clear that it would come at a cost of degrading quality. Misinformation and disingenuous distortions of the facts are deployed routinely through multiple vehicles within the media to bolster acceptance by legislators and the public.

• Under my leadership, the CSA will develop a robust strategy of enhancing communication about what we as anesthesiologists do, and what makes our role critical to safe and efficient peri-operative, obstetric, pain, and critical care. We will author white papers, confront misinformation with facts clearly explained, wade out into the community to sponsor forums with various community groups, lobby lawmakers and regulators, and deploy lawyers and lobbyists as needed.

2. The recently enacted federal health care insurance reform legislation, The Patient Protection and Affordable Care Act (PPACA) has provisions that, if actually put into play, may well destroy anesthesiology as we know it. To start with, it is an unfunded mandate, largely to be "financed" on the backs of practitioners. This is despite our very low contribution to escalating health care expenditures, which are largely from increased procedures and tests, as well as from pharmaceuticals and changing national demographics - the baby boom maturing into the Medicare boom. Half of the increased "access" in PPACA will be by expanding "insurance coverage" to the uninsured through Medicaid. In California, we have a population of 37 million, with 6 million MediCal enrollees, expected to grow to 9 million under PPACA in 2014, and an anesthesia conversion factor of $14 ($17 for OB), one of the lowest in the nation. At these rates, access is a pipe dream. Moreover, the "non-discrimination" clause, which bars insurers and others from discriminating against categories of practitioners who render "equivalent" service, introduces a federal civil rights issue into what is properly an issue of scope of practice. And even worse than that, the Independent Rate Setting Commission (IPAB) is populated entirely by all non-clinicians, and has been set up to slash Medicare spending in ways that are non-negotiable and not appealable.

• Under my leadership, the CSA will work with the ASA to analyze, understand, strategize, and then communicate to our members. There is a long and complex political story here, and ultimately only political action can save our patients from the devastating access problems that IPAB, if rolled out as scheduled, will surely produce.

3. Performance measurement is essential to improving quality. Pay for Performance (P4P) is one potential use of these measurements, and it comes in many flavors, many of which are fraught with unintended consequences. So, on the one hand we must measure, and therefore construct appropriate and robust measures for our specialty, report our outcomes to a national clinical outcomes registry, and be benchmarked against each other in various ways. On the other hand, we must resist the inappropriate use of measures using poor data and unadjusted for risk, and be extremely wary of publicly reported outcomes. We all must become experts in understanding how and why measures are constructed, their pitfalls, their pros and cons.

• Under my leadership, the CSA will educate its members and other relevant parties on why and what to measure and how to do it. We must educate, communicate, and exchange information with each other as this field continues to evolve. We will enlist the expertise of LPAD and EPD working together to try to bring clarity to a domain where there is now largely confusion and obfuscation.
  

4. Accountable Care Organizations (ACOs), proposed as one of the foundations of the coming brave new world of ObamaCare, are being pushed as a major new vehicle to improve quality patient care while reducing redundancy and cost. CMS has just published its rules on how ACOs should work to qualify for federal dollars, but commercial health care systems and hospitals have been strategizing and theorizing about this for quite some time. In some ways, this appears to me like a reinvention of HMOs, except that patients may drop in and drop out at will. Furthermore, there appears to be a shifting of financial risk within the next few years to physicians and the ACO entities, and away from an ultimate financial responsibility by the federal government. ACOs intend to foster competition between groups of doctors and institutions, and strategies being discussed touch upon corporate practice, foundation models, what some would consider kickbacks, and new systems of payment for medical services.

• Under my leadership, the CSA will promote sharing of perspectives and approaches, and analyses by various experts, locally, around the state, and nationally. When necessary, we will illuminate what appear to be illegal arrangements. We will share with our members ways to prove the value of our (extended) services, and explore the concept of a potential surgical "Home" as this idea and federal legislation to create it continue to be developed.

5. Advocacy- federal, state, and even local - is a cornerstone of advancing our agenda to promote an appreciation for what anesthesiologists do. If we anesthesiologists do not advance our specialty-specific concerns for our patients and our profession, and our suggested solutions, who will? It is not enough to assume that others who are more engaged will do what needs be done and financially support what needs be paid for. To do so, to continue to "punch the clock" and then go home to our families and our interests outside of medicine is shallow, unprofessional, and ultimately self-defeating during these turbulent times when we all have targets painted on our backs. We are in this together, and we need each other's energy and support. We must start with the doctor-patient relationship, and from that basis move to successively higher levels of political involvement. Sure, engaging marketing professionals may be one way to get some of our message out, but the best and worst public relations derive from our individual relationships with each and every patient and family.

• Under my leadership, the CSA will cultivate an army of writers who will prepare white papers, letters to editors, opinion pieces, and scripts for media. We will charge the EPD with developing educational materials beyond its proven expertise in clinical topics, some perhaps related to patient interactions. We will bring the ASA Leadership Spokesman Training Program back to California to train more spokespersons. Now that we have sufficiently developed the infrastructure to support our web capability, we will refocus on developing content. We will encourage district-level and even group-level political fund-raisers, refine our database of constituents and contributors, find new ways to enhance participation in GASPAC and ASAPAC, and port the ASA CAPWIZ system to California, to use it for state specific issues. The latter is now up and running.

Given these kinds of critical issues, what is the purpose of the CSA? What is its Mission? Let's take a moment to reacquaint ourselves with our mission.

    The California Society of Anesthesiologists is a physician organization dedicated to promoting the highest standards of the profession     of anesthesiology, to fostering excellence through continuing medical education, and to serving as an advocate for anesthesiologists     and their patients.

This is what the CSA is organized to do, but where would we like to be in a year from now, two years, five years? And what specifically can the CSA do for its members, of sufficient important for each to embrace membership? This is what we could define as the CSA Vision. While we have had sporadic strategic retreats of the BOD every few years, we do not now have a mechanism for ongoing strategic discussion. We do not now have a CSA Vision per se.

I hope to change that by having strategic planning - and therefore, a Vision setting - be a part of every BOD meeting. Between BOD meetings, our Executive Committee has the authority to act, and it does, sometimes meeting each month by teleconference - 8 people doing much of the day-to-day and month-to-month decision making for 4000 plus members. Our plate is too full of critical issues to have this few people meet this infrequently. The BOD is not - and cannot - be engaged because, even though e-mail discussions are ongoing, it just does not meet often enough to maintain involvement of the district directors who constitute the BOD. And if the Directors are not engaged, how can CSA members in the trenches become more engaged? This is something that must be changed.

Here is my Vision for the CSA. I would like the CSA to be the first and primary resource to which our members turn to become better informed on a broad range of practice affairs issues - white papers, discussions, sample policies, the disseminator of information and advice concerning regulatory requirements and visits by accreditors, and how best to evolve our practices to survive economically. I want the CSA to be there for our members, to anticipate their needs, and for our members to look to the CSA as their organization that will help them, educate them, and do battle for them. And in return, I would hope to see that CSA members will give of themselves to the CSA, to share what they know and what they see in order to preserve and advance anesthesiology. I want our members to become more engaged and involved, beginning at the level of our local districts, with our District Directors and our Delegates and Alternate Delegates stepping up to do this work as a professional responsibility.

Here is a much too busy list of ideas to promote engagement and involvement that will be available in the Bulletin and on our website, and for which I do not have the time upon which to elaborate just now:

• Gather and report information on changing local patterns of clinical practice.
  
• Coordinate local political action in the service of state or federal issues, including local lobbying.
  
• Construct a telephone/text chain list to mobilize for urgent action alerts.
  
• Recruit new CSA/ASA members by visiting non-participating groups and making presentations, engaging individual non-members and selling CSA membership to each.
  
• Recruit for GASPAC and ASAPAC by individual visits, presentations, etc.
  
• Participate in local activities sponsored by CMA components.
  
• Organize town hall forums to educate various lay groups about clinical anesthesia issues, better educating the public in what we anesthesiologists actually do.
• Organize educational meetings intended to stimulate civic engagement beyond just CSA activities, like with the Alzheimers Foundation, the National Institute of Mental Health, and Global Humanitarian Outreach.
• Organize or participate in rendering clinical care to the uninsured or bring care to patients in remote locations in CA or nationally or internationally through global humanitarian outreach..
• Organize local site visits for various government officials.
• Organize local dinner meetings for CSA district members, finding funding, speakers, and venues.
• Cultivate a liaison with anesthesia residency programs, encouraging residents to visit community practices, and faculty to participate in CME programs in the community.

Directors need not themselves do all or many of these activities, but each is a service. Each is an educational opportunity. Each enhances the CSA.

So the flavor of my strategic approach is to address this CSA Vision by enhancing engagement and involvement of each and every CSA member. I also am charging a new task force with analyzing the effectiveness of how our BOD functions, and to suggest how to improve it expeditiously. I also believe in the importance of the HOD, and the importance of involving you, our delegates and alternate delegates, more deeply. Yes, we need to engage and involve all of you good folks beyond just one annual meeting.

And what about lobbying to place CSA members on ASA Committees? At the ASA BOD, some years ago, there was a change from a House of Representatives to Senate model. We are 9% of ASA membership, and as such need to approximate that percentage of committee chairs and committee members, not the 3% or so that we now enjoy. We know how to get more folks appointed, but it must start by your wanting to be involved.

So, we anticipate a busy and productive year. Many projects have already been set up, some already under way during Dr. Trivedi's term, and some even ongoing from Dr. Hertzberg's year at the helm. We build on what we have already in play and what we have already accomplished. We stand on the shoulders of those who came before us. My plan is to try to stimulate and to expand engagement and involvement of members at all levels, to make the CSA feel closer and more useful and more user friendly for its members, to enhance communication, not only disseminating what CSA leadership thinks members should know about, but also to pull content and priorities and enthusiasm from those who labor in the trenches, at the District level, a real two way pipeline.

    The woods are lovely, dark and deep.
    But I have promises to keep,
    And miles to go before I sleep,
    And miles to go before I sleep.

                -Robert Frost, 1874-1973
                "Stopping by the Woods on a Snowy Evening," Copyright 1923

Thank you for being here. Thank you for listening. Thank you in advance for helping me to serve you. Together, let's work to reshape our CSA into the kind of professional organization that it can and should be.

    Comme disent les Français: Allons-y, mes amis. Nous avons beaucoup à faire.   

[i]The List:

• The nurse anesthetist opt-out

• PPACA

• Performance measurement

• ACOs

• Advocacy

• Educational Mission - new and improved meetings and new CA meeting, workshops, web-based content, modules, newer modalities

• Single payer system in CA

• MICRA

• Federation of state medical boards and MOCA vs MOSL

• AMRs and EMRs

• Bankrupt state treasury with public programs in the cross hairs

• Unsustainable increases in health insurance premiums

• Balance billing proscriptions

• SGR, 33% problem

• Potential for new collective bargaining entities, return to guilds

• AMA vs coalition of national specialty societies, one big tent and/or reach across specialties, hospital-based, surgical, specialists, etc.

• Sedation protocols and training

• CMS IGs - single service, specified notes and timing

• Drug shortages

• Surveys by state and feds, drug labeling

• Changing areas of education and practice

• Diversion

• Workers Comp rates

• Poaching by other medical specialties

• Transparency and Truth in Advertising

• AAs

• Reorganization in CSA (Communications Manager, high level staff roles, website, communication to members)

• CSA Model Guidelines

• Insurance abuses, balance billing, underpayments and delays