Annual Meeting of the Board of Directors – August 21-22, 2010

Director Report

“ASA – Advancing the practice and securing the future”

          The Annual Board of Directors Meeting of the ASA was held August 21-22 in Chicago.  The remarkable changes of recent years in the ASA organization continue.  The ASA is continuing its quest to become the “world’s premier medical specialty organization.” Its newest mission statement is listed above as part of the new 2011 – 2013 Fiscal Year Strategic Plan.

            Talk of Strategic Plans and Mission statements can be as soporific as 8% Sevoflurane but bear with me and I will come back to that point.

Political - Southern Caucus

            The weekend of meetings starts with the Caucus meetings on Saturday morning.  South Carolina along with the states of Alabama, Arkansas, Florida, Georgia, Louisiana, Mississippi, North Carolina, Oklahoma, Tennessee and the Commonwealth of Puerto Rico make up the Southern Caucus.  Our caucus remains VERY active in the political process within the ASA.  There are no contested races this year for offices and assuming there are no nominations offered from the floor at the HOD our Caucus will have Jerry Cohen as President Elect, Arnold Berry as VP for Scientific Affairs, Art Boudreaux as Secretary, and Steve Sween as Vice Speaker.

            Bottom line:  Our Southern Caucus is strong and contributes a great deal to the direction and forward motion of the ASA on a national level.  This is the cycle year for elections for offices within the Caucus as well.

Review Committee Hearings and Board Action (Saturday and Sunday)

            The Annual Meeting of the BOD consists of a large number of annual housekeeping items such a committee appointments and representation, annual reports of foundations, and committees.  Resolutions are also presented that are debated and then voted on for presentation to the HOD.

Our ASA is large and its organization is complex so this report will not be exhaustive.

 The House of Delegates (HOD) Handbook and the items for consideration this October in the HOD will be stunning in number if nothing else.  Some (not all by any means!) of the seminal issues discussed and approved by the Board on Saturday and Sunday are outlined below.

It is obvious from the table above, that the ASA is a member driven organization.  The House of Delegates controls this organization and it is at the Annual Meeting that this is and will be most evident.  Our delegates this year are Dr. P.Greg Lee, Dr. David Smith, Dr. Joe Carter and Dr. Terry Dodge.  Our resident delegate will be Dr. Jerrell Brown.  Serving as alternate delegates will be Drs. Rob Morgan, and Tedd Rothman.  Many thanks to them for offering to serve our society in this very important capacity.

Many actions of the BOD this past weekend will require scrutiny and approval or disapproval by the HOD in October.  That said, here are some of the weekend highlights

            Administrative Affairs

Within this Committee the President, Alex Hannenberg, reported on a number of notable items.

·        The Patient Protection and Affordable Care Act (PPACA) has been signed into law and the ASA has continued to monitor regulatory unfolding related to PPACA as well as pushed back as possible on a number of key items.  These include the obvious SGR fiasco.  The future of this issue is anyone’s guess at this point but  the ASA continues to work with legislators (such as John Kyl) for a permanent repeal. 

·        The Independent Payment Advisory Board (IPAB) made its appearance in the PPACA and ASA was early to sound the warning bells about this entity.  The hazards of this Board and its potential actions are even worse if SGR cuts are superimposed as well.  Hopeful news is that the ASA’s friends in the House of Representatives continue to attack IPAB.  Even the AMA, yes the AMA, has now put the IPAB danger high on its advocacy agenda!

·        The ASA has worked hard to increase the concern about the provider  “non-discrimination” provisions in the PPACA, even successfully gaining approval of a resolution in the AMA meeting of the HOD to urge repeal of  this provision.  This action dovetails nicely with continued promotion of the Healthcare Truth & Transparency legislation introduced in the U.S. House last spring.

·        PPACA also promises a change in how we are paid for our care of patients.  Bundled payments, ACOs and other alternatives to traditional fee-for-service are at the beginning of their creation by regulators.  Towards that end close scrutiny of the proposed 2011 budget reveals increased staffing in the Washington. D.C ASA office to assist our membership in dealing with these challenges.

·        In November of last year CMS published updated Interpretive Guidelines for the

Hospital Conditions of Participation on anesthesia services. ASA’s response has included contact with CMS to clarify and even offer substitute language for guidelines relating to preoperative and postoperative documentation.  Beverly K. Philip, M.D., and members of the Committee on Quality Management and Departmental Administration, have produced documentation templates to conform to the requirements of the Interpretive Guidelines. These are available on the Members Only  http://www.asawebapps.org/site/login.asp?TrackID=&VID=&CID=&DID=&TP=/site/vision_address_update.asp&MODE=0&Module_ID=10 page of the ASA website.

Dr. Hannenberg had appointed an ad hoc committee to address the issue of privileging of non-anesthesiologists  in deep sedation because of the need among ASA’s members for tools to satisfy this requirement in their institutions.  The pressure of the CMS Guidelines also made this a timely effort.  The BOD approved the committee’s recommendation for  “Advisory on Granting Privileges for Deep Sedation to Non-Anesthesiologist Sedation Practitioners”.  If approved by the HOD this advisory should be a vast improvement over past ASA positions on this thorny issue.  The general consensus is that this document is much better and will be of greater use to our membership as we attempt to lead in this area of sedation and patient care.  But remember, it will only be an advisory.

·        At the invitation of the ABA last year, the ASA BOD and the HOD voiced strong opposition to the creation of an advanced pediatric anesthesia certification process.  Well, the ABA has since requested that the American Board of Medical Specialties create a certification process in advanced pediatric anesthesia and the ABMS will begin consideration of this request this summer.  In keeping with the will of the HOD Dr. Hannenberg has communicated to the ABMS the ASA’s position on this course of action.

·        In 2010 a bit over $80,000 has been disbursed to state component societies to provide support for advocacy issues.  The states of Oklahoma, Iowa and Arizona all were facing scope of practice issues primarily in the practice of pain medicine.  The ASA leadership and the new Strategic Plan are placing an emphasis on enhancing membership support, satisfaction and participation.  More on that below.

            Dr. Mark Warner, as President-elect this year, has been responsible for leading the design, development and beginning implementation of a new strategic plan for the ASA.  It is extremely detailed and is available on the ASA website within the members section http://www.asahq.org/aboutAsa/ASAStrategicPlan.pdf   The strategic plan is intended and designed to be a working strategy. In essence, it is a road-map the ASA will use to ensure that it is improving, staying on course, and providing the resources that will allow the ASA membership to have a better, more successful organization in 2013 than we have today.  In particular, the ASA Strategic Plan calls for increasing membership through active recruitment and improving member services and value.  Metrics are being designed and assets are to be devoted to these goals and objectives.  The membership survey of  2009 indicated a need for improvement in the value that ASA members perceive both from the ASA as well as their component societies.

·        A resolution to have the BOD approve of ASA endorsement of ASA members running for AMA offices and positions was hotly debated but eventually defeated.  So it remains to the ASA AMA Delegation to offer ASA endorsement on their own decision process without ASA BOD review and approval.  Concern with AMA and its inability to reflect the concerns of the ASA runs high.  The ASA sends a sizable delegation to the AMA and a report from Dr. Arens was very informative.  Membership continues to drain from the AMA roles, the AMA leadership, including the two anesthesiologists on the Board, appear to have “drunk the kool-aid” (his words) being passed out by the administration.  The AMA is probably going to have to reorganize at some point in the future (his opinion) but no alternative coalition seems to be in the horizon at the moment.

·        For the time being, there is probably continued reason to maintain an ASA presence on the AMA as the AMA provides the ASA with a least $1 million a year worth of research, data and help with ASA issues. The AMA has also been helpful in litigation with insurance carriers such as Aetna and United.  AMA likewise serves as one of the parents of ACGME, ACCME, and makes appointments to many other organizations such as TJC, RUC, etc. This is another avenue for anesthesiologists to be appointed to these still important committees.  The AMA house also voted to pursue repeal of provider “Non-Discrimination in Health Care”.  This means the AMA will vigorously oppose this Act (2706) through letters to the Secretary of Health and ranking House and Senate members involved in health care issues. The Scope of Practice Partnership also has this issue on their advocacy agenda.

Now for some really big (70,000 square feet!) news.  The ASA leadership feels it is time to consider a new headquarters (HQ).  A report from the ad-hoc committee on future land use has vigorously studied the current HQ and has set forth recommendations that the HOD will vote on this October.  Basically, with an eye towards providing for the future growth and purpose of the ASA the BOD approved the committee’s recommendation authorizing the Administrative Council (AC) to select a site for construction of a new building or an existing building for a new ASA Executive Office, subject to the seven priorities (listed below) and begin preliminary negotiations for purchase, including

negotiation of financing.  Please note:   “the House of Delegates at its October 2010

meeting will vote on delegating final authority for selection of a new site or building, purchase of

said site or building, supervision of design and construction or renovation as required and negotiation of financing to the AC, subject to a budgetary limitation of $20 million dollars”.

·        Seven priorities for new HQ: (The building must be about 70,000 square feet and capable of further expansion over the next 20-30 years.  High capacity broadband must be readily available.  Parking for at least 250 cars.  Within walking distance or a short taxi ride to high quality hotels and restaurants (necessary if the executive office becomes a site for an education center).  Less than a 30 minute non-rush hour ride from O’Hare airport.  Convenient to public transportation.  Nearby green space).

·        The reasoning for considering a new HQ is related to current inadequacies and anticipated future needs.  Current limitations are: capacity limitations in seating and parking, inadequate conference room availability, very limited lunchroom facilities; maximum capacity to hold all staff meetings is 80 staff, inadequate kitchen facility, inadequate women’s restroom facilities – 75% female staff, and outdated Heating & Air Conditioning systems.  Anticipated future needs would include: anticipated growth in existing departments, growth of AQI initiative, new initiatives (publishing, education, etc.), adding staff liaisons to support Committee work, and possibly consolidating Foundation and Journal staff.

            Finance

            In summary, the balance sheet is in the black and with the addition of recent financial controls and staff related to the Organizational Improvement Initiative Blackman Kallick, LLP presented an unqualified audit report for 2009.  And I believe this is one of the first unqualified audit reports in many years for the ASA so good progress there. The budgeted 2010 change in net assets based on operating fund revenues of $36,770,569 is $889,554.  The budgeted 2011 change in net assets based on operating revenue of $38,149,000 is $1,190,000.  Please keep in mind that the proposed budget for 2011, though approved by the BOD, is subject to change and final vote by the HOD in October.  The level of detail in the financial tools now available to the ASA is very impressive.  Also, the strategic plan has been specifically tied to financial controls and metrics and regular measurement of the financial progress of the strategic plan will be ongoing.

Scientific Affairs

This committee oversees an enormous amount of the clinical activities related to the ASA membership.

·        A big discussion ensued and final approval was reached on a resolution to revise the ASA Recommendations for Infection Control for the Practice of Anesthesiology, to conform to current guidelines publicly set forth by CDC to state “Do not administer medications from a syringe to multiple patients, even if the needle or cannula on the syringe is changed. Needles, cannulae and syringes are sterile, single-use items. Do not reuse for another patient or to reaccess a medication or solution.”  The BOD did recommend that further reviews of the updated ASA Recommendations for Infection Control for the Practice of Anesthesiology include the pertinent portions of both the old version and the proposed revision for comparison.

·        The Committee on Pain Medicine, had completed a scheduled five-year review of the document entitled Statement on Anesthetic Care During Interventional Pain Procedures for Adults.  The following statement was approved by the BOD and will be presented for approval to the HOD in October:

“STATEMENT ON ANESTHETIC CARE DURING INTERVENTIONAL PAIN

PROCEDURES FOR ADULTS

Committee of Origin: Committee on Pain Medicine (Approved by the ASA House of Delegates on October 22, 2005 and last amended on October 20, 2010)

It is the opinion of the committee that the majority of minor pain procedures, under most routine

circumstances, do not require anesthesia care other than local anesthesia. Such procedures include

epidural steroid injections, epidural blood patch, trigger point injections, sacroiliac joint injections, bursal injections, occipital nerve block and facet injections. The use of general anesthesia for routine pain procedures is warranted only in unusual circumstances. The committee recognizes that conditions may exist that make skilled anesthesia care necessary for procedures not normally requiring such care. Major co-morbidities and mental or psychological impediments to cooperation are examples of conditions dictating anesthesia care for even minor pain procedures in unusual patients.  The use of sedation and anesthesia must be balanced with the potential risk of harm from doing pain procedures in a sedated patient, especially those undergoing cervical spine procedures.  Procedures that are prolonged and/or painful often require intravenous sedation and may warrant use of monitored anesthesia care (MAC). These include sympathetic blocks (stellate ganglion, celiac plexus, lumbar parvertebral), radiofrequency ablation (R/F), facet neurolysis (RF), discography, percutaneous discectomy and trial spinal cord stimulator lead placement. Some  committee members are of the opinion that selective nerve root/ transforaminal injections, particularly cervical transforaminal injections, warrant intravenous sedation and, at times, MAC.  Major nerve/plexus blocks are done less often in the chronic pain clinic, but the committee believes that these blocks do may warrant the use of intravenous sedation and, at times, MAC (e.g., brachial plexus block, sciatic nerve block, particularly continuous catheter techniques).”

Professional Affairs

This Board committee is home for a number of Committee reports that are crucial to the ASA membership in the areas of practice management and economics including the Committee on Performance and Outcomes Measurement (CPOM); Committee on Standards and Practice Parameters and Committee on Economics.  The BOD approved and the HOD will be asked to vote on the following Practice Parameters currently under development or revision:

“OPEN FORUMS FOR CENTRAL VENOUS ACCESS GUIDELINES

Open forums were held for the Practice Guidelines for Central Venous Access at the 2010

Annual Meetings of the Society for Cardiovascular Anesthesiologists (SCA), and the Society for

Pediatric Anesthesia (SPA). This task force is chaired by Stephen Rupp, M.D.; the draft practice guideline can be accessed through the ASA website at http://www.asahq.org/clinicalinfo.htm

PREOPERATIVE FASTING GUIDELINE REVISED AND UPDATED

The Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to

Reduce the Risk of Pulmonary Aspiration: Application to Healthy Patients Undergoing Elective

Procedures has been revised and updated. This task force is chaired by Jeffrey L. Apfelbaum,

M.D.; the draft practice guideline can be accessed through the ASA website http://www.asahq.org/clinicalinfo.htm

PRACTICE ADVISORY REVISED AND UPDATED

The Practice Advisory for the Perioperative Management of Patients with Cardiac Implantable

Electronic Devices: Pacemakers and Implantable Cardioverter-Defibrillators has been revised

and updated. This task force is chaired by James Zaiden, M.D.; the draft practice guideline can be accessed through the ASA website at http://www.asahq.org/clinicalinfo.htm

PREVENTION OF PERIOPERATIVE PERIPHERAL NEUROPATHIES

REVISED AND UPDATED”

The Practice Advisory for the Prevention of Perioperative Peripheral Neuropathies has been

revised and updated. This task force is chaired by, Jeffrey L. Apfelbaum, M.D.; the draft practice

guideline can be accessed through the ASA website at http://www.asahq.org/clinicalinfo.htm

Bottom Line:  ASA continues to work at enhancing patient care as well as integrating these advances with national forums and administrators that determine payment schemes.

Afternoon Session (Saturday)

The Board spent Saturday afternoon in sessions beginning with the ASA Candidates Forum.  As I mentioned above, there are no contested elections this year, unless challenges come from the floor at the HOD.  The candidates slate will thus have Mark Warner for President, Jerry Cohen as President Elect, John Zerwas as 1^st Vice President, Bob Johnstone as Vice President of Professional Affairs, Arnold Berry as Vice President of  Scientific Affairs, Jim Grant as Treasurer, Mary Dale Peterson as Assistant Treasurer, Art Boudreaux as Secretary, Linda Mason as Assistant Secretary, John Abenstein as Speaker, and Steve Sween as Assistant Speaker.

The Board spent the remainder of the afternoon in educational sessions on a number of issues as well as the familiar Legislative Update from Ron Zsabat and Lisa Albany.  A  more in-depth presentation about the Strategic Plan was presented by Mark Warner.  Again, a primary focus of the ASA going forward is going to be on membership services and satisfaction.  The ASA is committed to improvement in these areas.

Of particular note a very enlightening and hopeful talk was given by Dr. Richard Dutton of the new Anesthesia Quality Institute (AQI). The core principle of the AQI is that “knowledge is power”.  Salient take home points were that the AQI is:

            Pursuing all electronic data capture,

Open to every practice in the US,

            Housed internally at the ASA,

Open accessible standards and definitions,

No competition with software vendors,

d-identified patient data,

Emphasis on private reporting.

The AQI is actively enrolling practices.  Dr. Dutton wants you and your practice.  If you have any interest in participating contact him at mailto:r.dutton@asahq.org   The AQI is currently collecting

billing data, QM data, AIMS data, and hospital EHR data.

The AQI  Registry will select all cases and build the” pipes” to download data.  Basically once a practice or individuals are approved to participate, the AQI sends in its IT folks to build the needed links to the practice’s database and potentially the hospital’s as well if that is negotiated.

Currently the cost is free but in 2011 it will increase to $500 per physician though it will remain free to ASA members.  The Registry has the ability to capture and report on a number of outcomes including mortality and “near misses”.

 The “next steps” for the AQI will be to expand recruiting and data density, Comparative Effectiveness Research and development of best practice resources.  Dr. Dutton welcomes your input and yes, your data!

Conclusion

It remains a privilege to serve as your ASA Director, representative to the Carrier Advisory Committee to PGBA as well as representative to the SCMA Interspecialty Council for the SCSA.  Your support, sacrifices, advocacy, efforts and contributions to the SCSA, ASA and the larger house of medicine are invaluable.

The SCSA response to the ASA member survey in 2009 included 54 respondents.  Amongst those responding only 53% felt that membership in the SCSA was valuable to them.  In addition, only 44% felt that membership in the SCSA was important to their ASA membership experience.  There is room to improve.

There is just no way I could squeeze every report and detail into this missive for you so if you have any questions or concerns please contact me.  I will address them as best I am able.

For those of you that will be attending the ASA in San Diego be aware it is going to be a different meeting in many ways so please read through registration material and look at the preview site as well http://www.asahq.org/ePreview/  For starters, the Opening Session has been designed to make a big first impression with Jeff Skiles, USAirways Flight 1549 co-pilot (“miracle on the Hudson”), as a guest speaker and that evening, assuming the Padres do not make it to the playoffs, a reception will be held at PETCO Park.

I look forward to seeing you at our upcoming meeting in Pinehurst along with our North Carolina colleagues!

Respectfully submitted,

Christopher A. Yeakel, MD, FAAP

mailto:cyeakel@sc.rr.com

(Cell) 803-312-2592