stream and brain tissues or nerve fibers dwindles from the levels required to maintain anesthesia down to levels approaching zero, the normal reactivity of the nerve tissue is resumed. Partially-conscious patients must be cared for until full consciousness has returned and protective reflexes have been regained. The ultimate objective of a well-planned and carried-out anesthesia procedure is to interfere as little as possible with the essential bodily processes, thus insuring an uneventful recovery of the patient from the combined surgical and anesthetic undertaking. A nurse anesthetist, if so designated, shall remain with the patient as long as necessary to stabilize his condition. The recording of post-anesthetic visits that include notes describing the presence or absence of anesthetic-related complications must be made. STANDARD IX Appropriate safety precautions shall be taken to insure the safe administration of anesthetic agents. Interpretation Safety precautions and controls, as established within the institution, should be strictly adhered to, so as to minimize the hazards of fire and explosion in areas where flammable anesthetic agents are used. Anesthetic apparatus should be inspected and tested by the anesthetist before use. If a leak or other defect is observed, the equipment should not be used until it is repaired. The CRNA shall check the readiness, availability, cleanliness, and working conditions of all equipment to be utilized in the administration of the anesthetic agent. Proper clothing and footwear should be utilized in accordance with the established rules and regulations at the health care institution in which the anesthesia is administered. STANDARD X The practices employed in the delivery of anesthesia care must be consistent with the policies, rules and regulations of the medical staff of the institution in which the anesthesia care is rendered. Interpretation The conduct of the CRNA is governed by the policies, rules, and regulations as established in the health care institution in which the anesthesia care is being provided. These policies, as well as the extent of the responsibility delegated, should be closely adhered to. STANDARD XI Compensation for the rendering of anesthesia care must be made within the norms established by the code of ethics of the American Association of Nurse Anesthetists and the general rules and standards adopted by the profession within each locale. Interpretation The CRNA must assiduously guard against exploitation of the patient of any participation in practices which would be contrary to the best interest of the public. General rules and standards regarding remuneration may be adopted by the profession within each locale which are to be governed by policies and laws of that locale. The right to be adequately remunerated for the services rendered is recognized as well as the counterbalancing obligation to protection the patient from economic exploitation. Nurse anesthetists are free to render gratuitous services. Senator TALMADGE. Thank you very much, Ms. Ecklund for your helpful and constructive suggestions. We will review them carefully, the recommendations you have made, and urge you and your associates to continue to work with the staff of the committee and members of the committee in trying to develop this legislation as constructively as possible. Next and the final witness for the day is Dr. John W. Ditzler, president, American Society of Anesthesiologists, and Michael Scott, counsel. Doctor, I want to thank you and the organization you represent for your very helpful and constructive suggestions that you have made in trying to develop this legislation and urge you and your society to continue to work with the staff and members of the committee in developing it as it goes through the legislative process. STATEMENT OF DR. JOHN W. DITZLER, PRESIDENT, AMERICAN SOCIETY OF ANESTHESIOLOGISTS, ACCOMPANIED BY MICHAEL SCOTT, LEGAL COUNSEL Dr. DITZLER. Mr. Chairman, I am Dr. John Ditzler, an anesthesiologist from Chicago, Ill. I am a professor of anesthesiology, Northwestern University School of Medicine, and am, in addition, the Chief of Staff of the Veterans' Administration, Lakeside Hospital, Chicago, from which I am on annual leave to make this presentation. I speak today as the president of the American Society of Anesthesiologists, a physicians' organization. Senator TALMADGE. I am the ranking member of the Veterans' Affairs Committee. I hope it is not necessary for you to take annual leave to testify before a committee of the Congress. As I understand the Constitution of the United States, every citizen in America has an inalienable constitutional right to petition his Government for redress of grievances. You may proceed. Dr. DITZLER. I am accompanied by Mr. Michael Scott of the firm of Cox, Langford & Brown, the society's legal counsel in Washington. I would make it clear at the outset that our testimony addresses itself solely to the portions of the bill which specifically relate to anesthesiology and the delivery of anesthesia care for the American people. The primary goal of the members of our society is the delivery of superior anesthesia care. We believe that such care is optimally provided by a well-trained physician working with one patient, a ratio of one to one. We have believed in that concept and have implemented many of our policies with this in mind ever since the inception of the American Society of Anesthesiologists nearly 40 years ago. We have had problems with sufficient qualified anesthesia manpower, and would, only incidentally, call to your attention the need for special consideration for specialties such as anesthesiology when considering the overall United States manpower needs for physicians. The American Society of Anesthesiologists realizes that it has an obligation to all of the American people, and, that with well over 16 million anesthetics given per year, our current society strength of approximately 10,000 active members cannot provide the optimal oneto-one care, especially since anesthesiologists are now increasingly also engaged in intensive care units, pain centers, and pulmonary therapy support. In many areas of the country there are a variety of methods of delivery of anesthesia care, some of them historical, some of them new and innovative, and others bringing with them some concerns. We believe, therefore, that Senate bill S. 3205 is commendable in that it recognizes that in order to provide superior care to the American public, one must not only continue to recognize the optimal one to-one relationship of the anesthesiologist to his patient-one must also provide for proper and appropriate medical direction of the nonphysician anesthetist. The definition of proper and appropriate recompense for anesthesiologists' services has been a subject of concern within our society for over 20 years. Contrasted with those individuals who believe that optimum care involves a one-to-one relationship, there have been others who have proposed that the physician need only be responsible for the medical direction of nonphysician anesthetists and that they, therefore, could appropriately provide unlimited supervision. This latter attitude has led to practices which we as a society do not regard as optimal patient care nor perhaps in some cases adequate patient care. It seems to us that for medicare purposes section 22 of the bill does provide a reasonable solution under these difficult circumstances. The bill permits reimbursement to physicians for anesthesia care services both in the context of the one-to-one relationship and also in the context where it is clear that medical direction of nonphysician anesthesia personnel is medically proper. By negative implication, however, the bill disqualifies for reimbursement those physician services where personal performance or personal direction cannot, as a medical matter, be accomplished. We thus support that portion of section 22 dealing with anesthesia services as long as it is also recognized that section 22 does not enumerate all of the circumstances in which an anesthesiologist performs legitimate patient care services. You will find attached to our written statement a proposed revision of the pertinent portion of section 22 dealing with practical problems of anesthesia care, to which we hope the subcommittee and its staff will give serious consideration. I would like finally to turn to a subject not directly raised by the bill itself but which has been raised by you. Mr. Chairman, in your speech on the Senate floor, introducing the bill, as well as this morning a few moments ago. We firmly support the use of professionally prepared relative value guides or scales as one valuable mechanism for determining appropriate physician reimbursement, and further support the notion that development and use of such guides or scales should be validated as a part of the legislation now under consideration. As the subcommittee is aware, our society is currently engaged in litigation with the U.S. Department of Justice over our development and dissemination of a relative value guide. Briefly stated, this guide attempts to establish, on the basis of complexity of procedure, time er effort necessary for its completion, and other medical considerations, a relative value in unit terms, not in monetary terms, for a variety of medical procedures of the type performed by members of our society. We understand that your chairman's legislative proposal would validate the use of such a guide as long as it is not stated in monetary terms and as long as it is only what it purports to be-a guide. As a practical matter, a well-developed and thoughtful guide would prove extremely valuable to all concerned. The society strongly supports your chairman's effort in this respect. and urges the members of the subcommittee and its staff to give it most serious consideration. We believe that contrary to the position which will apparently be taken by the Department of Justice, dissemination and use of relative value guides will have a salutary rather than an adverse effect. Mr. Chairman. this completes my oral testimony, and I will be pleased to answer your questions. Senator TALMADGE. Thank you very much. We appreciate your very constructive suggestions and they will be considered carefully by members of the subcommittee. Again, I want to repeat. I hope you and your organization will continue to work with the staff and memhers of the subcommittee as we work toward a legislative solution for this very difficult and complex problem. I have only one question. Did you hear Ms. Ruth B. Ecklund testify in behalf of the American Association of Nurse Anesthetists? Were you in the audience? Dr. DITZLER. Yes: I heard it. Senator TALMADGE. Would you care to comment on her statement? Dr. DITZLER. I would care to comment in one area particularly. The statement has been made that the nurse anesthetist provides the coverage in perhaps 40 percent of the hospitals in this Nation. I think one has to also take into account that this represents perhaps only 10 percent of the anesthetics administered in the Nation. This is in large part due to many of our hospitals being of 50-bed capacity or less. I think in part this reflects the deficiency of our health care delivery system in the country rather than relating to a national problem of anesthetic administration. The second part of the testimony as I heard it, related to the changing of wording indicating "any individual," and I would require closer reading to understand what the intent was, but surely it is correct that an anesthesiologist is not present in every situation where anesthesia must be administered. I would call to your attention that by law in all of the States, a physician must be responsible for the administration of the anesthetic even though it may be administered by a nonphysician. It is a physician and in those cases, it certainly would be the surgeon or obstetrician or other qualified physician to whom the ultimate responsibility for the anesthetic must rest. I have no other comments. Senator TALMADGE. If you have any further comment, after reading the statement in detail, we would appreciate your information. The subcommittee will stand in recess until 8 a.m. tomorrow morning. [The prepared statement and letter of Dr. Ditzler follow:] STATEMENT OF THE AMERICAN SOCIETY OF ANESTHESIOLOGISTS SUMMARY 1. The use of the term "hospital associated physicians" in Section 22 is misleading and should be changed. 2. Optimum anesthesia care involves a one-on-one relationship between anesthesiologist and patient. Anesthesiologist manpower limitations may, however, necessitate patient care in less than optimum conditions, in which event ethical principles require that medical direction of non-physician providers be given. 3. While raising certain negative implications concerning right to reimbursement for legitimate anesthesiologist services, Section 22 as it relates to anesthesiology is generally in accord with the Society's ethical guidelines. 4. Prohibition in Section 26 against use of certain percentage of collection billing practices, through use of independent billing organizations, is too broadly stated. 5. Proposed validation of dissemination and use of professionally-developed relative value guides is entirely meritorious and in the interest of all concerned with Government-financed medical insurance. STATEMENT My name is John W. Ditzler, M.D. I am a practicing anesthesiologist in Chicago, Illinois. I am a Professor of Anesthesiology at Northwestern University School of Medicine and in addition am Chief of Staff of the Veterans Administration, Lakeside Hospital, in Chicago. I testify today on behalf of the American Society of Anesthesiologists, an organization of physicians of which I am the current President. My testimony represents the position of the Society, approved in principle by our Administrative Council, on those issues raised by S. 3205 which are of particular interest to the Society and its members. With minor exception. I do not intend to deal with those aspects of S. 3205 which concern organized medicine generally, as I anticipate that these subjects will be covered by testimony of the American Medical Association and others. The membership of ASA consists of over ten thousand licensed physicians engaged in the recognized specialty practice of anesthesiology. While, as is commonly understood, anesthesiologists are principally concerned with the administration of anesthetic agents as a part of surgical or obstetrical procedures, they also engage in an increasing variety of related medical activities, particularly including pain therapy, respiratory therapy, and intensive care. We are indeed today witnessing the development, within anesthesiology, of various subspecialties: a development which I fully endorse in light of the increasing complexity of our profession. In S. 3205, anesthesiologists are referred to as "hospital associated" physicians-essentially, I assume, because most of the medical services of anesthesiologists are performed within the physical confines of a hospital. Unfortunately, however, this term carries with it another connotation or implication, that is, that anesthesiologists are in some form of employment or agency relationship with the hospital. This implication is misleading: with only minor percentage exception, anesthesiologists perform their services as independent medical professionals, and are compensated for these services on the basis of a fee charged to the individual patient. They are no more "hospital associated"-or to use another misleading expression: "hospital-based"-than for example are the surgeons or obstetricians who form a part of the medical care team with which the anesthesiologist is most frequently involved. If then the Subcommittee finds it necessary to refer generically to certain medical specialties practiced in the hospital setting, the Society believes it far more appropriate, and not misleading, to use the expression: "certain physicians' services normally performed in a hospital." The Subcommittee may well wonder why I choose, in testimony with respect to an important piece of proposed substantive legislation, to pause at the outset over what appears to be a minor definitional problem. To the members of our Society, the answer is quite simple: use of the terms "hospital-based" or "hospital associated" in relation to anesthesiologists, and for that matter, pathologists, radiologists and others, connotes that somehow these specialists are less independent than, or somehow different from, other independent professional specialists who perform in a hospital setting but as to whom, for reasons not clear, the terms are never employed. This differentiation causes the average anesthesiologist to see "red". Anesthesiology has emerged in the past three decades as a recognized and vitally important field of independent medical specialization and practice. Many operative procedures performed in 1976, that could not have been performed in 1956 or 1966, are possible not so much because of new surgical techniques, but because of the enormous strides which have been made in the science and art anesthesiology. Our members are proud of these accomplishments and of their independent status in the profession and in relation to the individual patient. They are thus |