Creative Marketing Concepts Newsletter ASSA

A SSA Alabama State Society of Anesthesiologists President’s Letter

Malpractice Insurance Involves More than Just Price Harper Wood, ProAssurance

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hances are that you – or one of your peers – will face a medical malpractice lawsuit at least once in your career. And with the changing face of the delivery of healthcare as a result of the Affordable Care Act, it’s of prime importance to select a carrier with the financial strength and stability to weather the storm.

Choosing the right carrier can be difficult, especially in this era of increased competition for your dollar. Difficulty aside, it’s one of the most important decisions you’ll make for your practice and your career.

It’s understandable to weigh carriers based on premium, but choosing one solely based on price can be a financial disaster. Consider a recent example reported

by Medscape.com: A risk retention group operating in a few states entered into what is known as “run-off,” or “a strategy for winding down insurance operations.”

When this occurs, a carrier stops collecting new premium – meaning any future claims must be handled with the finances on hand. Given that the typical cycle of a malpractice claim is 3-5 years, hypothetically, those insured physicians may be liable for claims if those finances are depleted.

Or, consider the example of carriers offering loyalty programs – where monies are promised if you remain with that carrier. Currently, some carriers are not required to account for the monies to be used for these future obligations. And the absence of that accounting on balance sheets can present an unrealistic picture of a company’s financial health.

When choosing a carrier, it’s a good idea to carefully consider its financial stability.

Ratings agencies such as A.M. Best (www.ambest.com) and Standard & Poor’s (http://www.standardandpoors.com/home/en/us) are useful resources – these agencies continually evaluate carriers and issue ratings indicating their assessment of the carriers’ financial stability.

It’s also a good idea to evaluate the carrier’s approach to claims handling – is the approach local? Does the carrier involve the physician in the development of a defense? Will the carrier force a settlement without a physician’s consent? What is the experience and caliber of the attorneys the carrier will involve in developing a defense? Equally as important is a carrier’s approach to underwriting – is it disciplined, i.e. are the risks the carrier underwrites carefully considered, or does the carrier underwrite any and all physicians? A disciplined approach to underwriting leads to a stronger bottom line.

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Spring 2013

ASSA Officers Jenny Dollar, M.D. President Blair Smith, M.D. President-Elect Aimee Walsh, M.D. Secretary-Treasurer Greg Bouska, M.D. Immediate Past President Richard Carson Executive Director Michael C. Gosney, M.D Editor P.O. Box 241453 Montgomery, AL 36124 334.954.2577 Fax: 334.269.5200 Email: ASSAexec@aol.com

Website: www.theassa.com

The President’s Corner Jenny Dollar, M.D.

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or my first President’s message, I would like share with the membership of ASSA a little about myself. My name is Jenny Dollar, and I am in private practice at Pediatric Anesthesia Associates, P.C. in Birmingham. Additionally, I am the Service Chief of Anesthesiology for Children’s of Alabama (COA). My practice group also works with the UAB Department of Anesthesiology by training resident physicians during their pediatric anesthesia rotation at COA. During my anesthesiology residency training at UAB, I was first introduced to the ASSA and ASA. I feel truly fortunate that early in my career I was exposed to organized medicine through the activities of our professional society. I have learned so much from other anesthesiologists around our state about regulatory and practice management issues. Most importantly, I developed a habit of participation in ASSA and ASA, as well as annually contributing to the ASSA lobbying fund and ASAPAC. My participation in the state society has led to involvement with the Jefferson County Medical Society, Jefferson County Board of Health, and MASA. I am always proud to represent the ASSA and our members at the county, state, and national level. When we join together as anesthesiologists and then with the rest of the house of medicine, we have a much louder voice and greater impact which will ultimately benefit our patients and our practice in the field that we enjoy.

I believe that physicians are facing one of the most challenging times in modern medicine. I don’t have to tell you that change is on the horizon, for it seems every time I open the newspaper and tune in to the local and national news there is information regarding our current healthcare system and how it may look in the future. During the next two years of my presidency, anesthesiologists will face evolving Medicaid and Medicare programs, and implementation of PPACA will begin in earnest. Anesthesiologists should be prepared to take the opportunity to participate and help direct these shifting entities through the ASA and its related programs, such as the Perioperative Surgical Home and the Anesthesia Quality Institute.

I look forward to serving the members of ASSA as president for the next two years. I also hope to see many of you at the ASA legislative conference, ASA annual meeting, and ASSA annual meeting. Please feel free to contact me with any questions, concerns, or ideas that you may have.

Jenny Dollar, M.D.

Malpractice Insurance Involves More than Just Price (continued from page 1) Physician involvement is another key consideration – who understands what a physician goes through during a lawsuit better? For example, ProAssurance historically has had physicians involved in our various committees and advisory boards. And we offer a Litigation Collaboration Network, in which physicians who are facing a lawsuit for the first time may access support and advice from colleagues who have been through the process. This provides firsthand experience regarding what to expect – both personally and professionally.

Another key to making an informed choice is to closely evaluate a carrier’s risk management services and programs, such as seminars that provide CME, hotlines for your risk management questions, risk management guidelines and self-assessment tools, sample forms, etc. Strong risk management resources can help a physician minimize risk while maximizing care delivered.

The competition for your dollar is fiercer than ever, but there are many more factors that go into a malpractice policy than just the price.

Ask yourself: “Is my carrier strong and stable enough to be around when I need them and to defend me to the best of its ability?” It’s a fair question.

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Leadership

The Most Important Renewable Resource Abe Schuster, M.D.

In this newsletter, you’ll read a lot about the ASSA going green. In my view, the most important resource needed to sustain and reinvigorate our organization is leadership. In this article, I will introduce you to some of our key leaders on the national level as well as our newly elected slate of ASSA officers for 2013-14.

John Zerwas, M.D., is our new ASA president. John is from Houston where he was instrumental in forming Greater Houston Anesthesiology (GHA) from several smaller entities. This large private practice is a model of how a large city-wide group can provide high quality perioperative services using the anesthesia care team model. In addition to his responsibilities at GHA and the ASA, Dr. Zerwas serves as a Texas State Legislator. He has earned the trust of his constituents and colleagues. There is no doubt that his political experience in Texas will help him navigate the politics of the ASA. It will certainly assist Dr. Zerwas in his role as Advocate in Chief for Anesthesiologists and our patients. Dr. Zerwas is an ideal leader with the perfect skill set for the ASA at this time. I have complete confidence in his success.

Another national leader to keep your eyes on is our very own Jeff Plagenhoef, M.D. Jeff was elected to the ASA Assistant Secretary position in a hotly contested race last October. He edged out a highly respected academic anesthesiologist from New York. I believe the voting delegates felt that Jeff’s passion and work ethic would best serve the ASA at this critical juncture. Jeff is in private practice in Dothan. He is an expert on the Anesthesia Care Team, Anesthesia information systems, and Quality. As you may already know, he is also very passionate about Dr. Tom Moore and Dr. Dollar visit advocacy and the ASAPAC. during the ASSA Annual Meeting.

On the State level, Jenny Dollar, M.D., is our new ASSA president. While still young, Jenny is anything but green.

She is an experienced, well respected leader of her group at Children’s Hospital in Birmingham. She has served in leadership roles in the Jefferson County Medical Society as well. Jenny is kind and thoughtful and has a complete grasp of the challenges we face in Anesthesiology. We are very lucky to have her as our president. In addition to being a delegate to the ASA, Jenny will also serve as the alternate director from Alabama on the ASA board of directors. This position was left vacant when Dr. Plagenhoef ascended to Assistant Secretary.

Our Past President is Dr. Greg Bouska. Greg is in private practice in Huntsville. He has done an exemplary job over the past 2 years and is available to counsel Jenny as needed.

Blair Smith, M.D., is ASSA President-Elect. Blair is a highly respected faculty member in the UAB Department of Anesthesiology. During his term as Secretary Treasurer of the ASSA, Blair did an excellent job educating private practice, faculty, and resident physicians about the ASSA and our common stake in the success of its endeavors.

The membership and leadership were also sensitized to the importance of the UAB training program. We are lucky to have this excellent program in Alabama and Dr. Smith as a leader in the ASSA. Aimee Walsh, M.D., is our newly elected Secretary Treasurer. She practices pain medicine. She has been a faculty member at UAB and is now in private practice in Mobile. Aimee is passionate about assuring that the ASSA fully represents the needs of Pain physicians and their patients. She is also passionate about advocacy and represents us as a board member on the ASAPAC. From my perspective, we are represented well on all fronts. Our national leadership is bright, enthusiastic and politically savvy. They have an excellent understanding of the Anesthesia Care team which is so prevalent in Alabama. Our state leadership is enthusiastic and diverse. They represent all geographic areas of the state. They are in Academics, Private Practice, and Pain Medicine. Most importantly, they all possess the will and desire to advocate for our specialty and the safety of our patients. I, for one, have never been more proud to be a member of the ASSA. 3

Alabama’s Federal Health Insurance Exchange Greg Bouska, M.D. Alabama’s Federal Health Insurance Exchange is to be implemented by 1 October of this year and set to be operational by 1 January, 2014. The Exchange is simply a market place where employers or individuals can purchase an insurance product designed by the government. The Federal Insurance Exchanges come in different flavors depending upon how much you want to spend.

There are Bronze, Silver, Gold, and Platinum plans which correspond to varying amounts of coverage. This is similar to shopping at the Dollar General, Walmart, Macy’s, or Neiman Marcus. Now here’s the rub, the State runs the Federal exchange but has little authority of how it is set up. This is fraught with errors.

Exchanges will be open to individuals buying their own coverage and employees of firms with 100 or fewer workers (50 or fewer in some states). Most Americans will continue to get insurance through their jobs, not via the exchanges. Most will be people who are eligible for subsidies, which will average an estimated $4,600 per person in 2014. Undocumented immigrants will be barred from buying insurance on the exchanges.

Unfortunately, the Federal Exchange website will be more complex than existing health insurance sites. People will be able to compare policies sold by different companies. Purchasing insurance can be confusing, so information on the plan benefits will be standardized in an effort to make it easier to compare cost and quality. Plans will be divided into four different types, based on the level of benefits: bronze, silver, gold and platinum. The exchanges are also required to operate toll-free hotlines to help consumers choose a plan, determine eligibility for federal subsidies or Medicaid, rate plans based on quality and price and conduct outreach and education.

Plans will have to offer a set of “essential benefits.” Those details, still being developed by the Obama administration and states, will include hospital, emergency, maternity, pediatric, drug, lab services and other care. Annual costsharing, or the amount consumers must fork over before insurance payments kick in, will be capped at the amounts allowed for health savings accounts -- currently, nearly $6,000 for individual policies and $12,000 for family plans. The premiums will vary by type of plan and location. Insurers won’t be able to charge more based on gender or health status. They will be able to charge older people up to three times more than younger ones.

The health law expands Medicaid to all people who earn less than 138 percent of the federal poverty level, $14,856 in 2012. However, the Supreme Court ruled in June 2012 that states have the ability to opt out of that Medicaid expansion, and it is not yet clear how many states will do that. Above the 138 percent level, sliding scale subsidies for private insurance on the exchanges will be available for residents who earn up to 400 percent of the poverty level, about $44,680. Most people will be required to have coverage of some sort beginning in 2014.

In general, there should be little difference between State and Federal Insurance Exchanges. Consumers shopping in either type of exchange will choose among insurer offerings that are standardized into four coverage levels: bronze, silver, gold and platinum. There will also be a young adults’ plan. Rules on how much insurers can vary premiums based on age or geography are set in the federal law, although states could adopt rules making them stricter.

Differences between federal and state exchanges are likely to be subtle, but important to some consumers.

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ASAPAC: It Matters Now More than Ever

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big thank you to all who donated to the ASAPAC this past year! Our state is highly ranked in at least two areas…football and donating to the ASAPAC. We did extremely well with donations and finished only second to Florida, who raised a record number of dollars. Alabama has once again been the leader in the drive to raise funds to support our PAC, and most other states look to us with admiration as doctors who care enough about our specialty to support it with time, money, and involvement in the issues that are important to us and our patients. One of the most important groups for us to recognize is the UAB residents who once again last year had a 100% participation rate. They are truly the future leaders of our specialty and have inspired many other residency programs to try to achieve a 100% participation rate “just like UAB.” As these doctors go out into the different communities after graduation, they are often the only ones in their practice that donate to the ASAPAC, and we look to them for leadership in the future. The fiscal year for the PAC has been underway for six months, and we are in great need of donations to once again allow us to be the leaders for the rest of the country.

Now is not the time to allow fatigue to set in to our attitudes or our actions. We have many challenges but also opportunities ahead to distinguish ourselves in the medical dialogue that will occur, particularly as it relates to patient safety and quality of care.

The ASAPAC has become America’s largest physician PAC for the third consecutive year, and we were the most successful health care PAC in the 2010 election cycle according to Politico & Kaiser Health News. In fiscal year 2011, we had a record year with almost $1.7 million raised and a 19.7% national physician participation rate.

In 2012, $1.8 million were raised, and we had a 21.4% participation rate. In Alabama, even though we did very well and were second overall, our participation rate went down and our total dollars went down as well.

Our participation rate is better than the national average, but we definitely have a long way to go. An average participation rate of 21.4% sounds good compared to previous years, but more than 1 out of 5 anesthesiologists that I know are unhappy with the direction of medicine and many of the changes that seem to be out of our control. Think of the message we could send to the world of politics if the other 4 out of 5 doctors donated to the PAC. Our donations would then far exceed any other group, and our voice would be too loud to ignore.

Founded in 1991, the ASAPAC is the political component of the ASA whose funds are devoted to advocating for political issues and candidates on behalf of all anesthesiologists. It allows us to actively participate in elections to the US House of Representatives, US Senate, and some gubernatorial elections. The PAC works to support candidates who support anesthesiology and to oppose candidates who do not share our views. Physicians often ask, “Why should I give to the PAC?” It is the primary venue we have as anesthesiologists to influence positive political change in the field of medicine. The real state of affairs in politics today is that PAC groups must be very generous in supporting candidates who represent our interests. We can make our views heard through constant and focused advocacy, and we can best do that through the ASAPAC. Please feel free to donate now and be done with it for the year.

Options for donating: 1) www.asahq.org.

Member log in. Username is first initial, last name (lowercase, no spaces). Password: membership number. If you do not know your member number and request your password, it only takes about 30 seconds for it to be sent to you. 2) Check to ASA Political Action Committee, 520 N. Northwest Highway, Park Ridge, Illinois 60068.

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The ASSA delegation to the ASA Legislative Conference: From L to R: Jeff Plagenhoef, Pete Hendricks, Tom Sawyer, Aimee Walsh, Jenny Dollar, Greg Bouska, Mike Lasecki and Blair Smith.

Alabama Medicaid Program to be Revamped

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n March, legislation was introduced in both the Alabama Senate and House that would completely change the manner in which the Alabama Medicaid program is administered. The legislation was introduced by Senator Greg Reed (SB 340) and Representative Jim McClendon (HB 454) and is based on the recommendations of the Governor’s Medicaid Advisory Commission. The Commission supported the community care outcomesbased approach to revamping the Medicaid program. The Commission’s recommendations have been supported

by MASA, Alabama Hospital Association, Alabama Nursing Home Association and an association representing Federally Qualified Health Centers.

The legislation calls for a transformation of the current Medicaid program into a managed care plan establishing Regional Care Organizations (RCO) or Alternate Care Providers (ACP) which will coordinate care and be paid for services reflective of outcomes and quality rather than fee-for-service. The state will be divided into eight geographic regions, each of which should be able to support at least two RCO’s or ACP’s. If the legislation is passed, these regions should be established by October 1, 2013. An RCO will contract with any “willing hospital, doctor, or other provider” if the provider is willing to “accept payments and terms offered by comparable providers.” The legislation defines ACP as “a contractor, other than a regional care organization, that agrees to provide a comprehensive package of Medicaid benefits to Medicaid beneficiaries in a defined region of the state pursuant to a risk contract.” In regions that contain more than one RCO, enrollees may choose between the different options. If no choice is made by the enrollees, he or she will be assigned.

The legislation sets forth a timeline to accomplish the transformation of the Medicaid program. An RCO should establish a governing board and structure by October 1, 2014. Each RCO’s governing board must be approved by the Medicaid agency and include at least two physicians, two hospital representatives, one dentist, one optometrist, one pharmacist, and the chair of the Citizen’s Advisory Committee, of which 20% must be enrollees in the program. By April 1, 2015, a probationary RCO must demonstrate the “ability to establish an adequate medical service delivery network.” The legislation decrees that a probationary RCO meets “solvency and financial requirements” by October 1, 2015, and prove its capability of providing comprehensive patient care services one year later. This legislation does not directly address the Medicaid long-term care system until October 1, 2017, when it states that long-term care should be integrated into each RCO. However, it does require the Medicaid agency provide an evaluation of the existing long-term care system to the legislature and governor by October 1, 2014.

This legislative effort is timely as the state struggles to fund the current Medicaid program. The General Fund Budget for 2014 maintains level funding of the Medicaid program at $615 million. It has been estimated by Dr. Don Williamson, State Health Officer and Medicaid Advisory Commission Chair, that the program needs approximately $740 million dollars on order to maintain what has been described as a “bare-bones” program.

Governor Robert Bentley has declared that Alabama will not participate in Medicaid expansion as part of the Patient Protection and Affordable Care Act (PPACA). He also has not expressed a desire to seek out Medicaid expansion through purchasing private insurance with federal dollars as the state of Arkansas has been approved to do.

With only a few days left in the current legislative session, it remains to be seen what the final outcome will be for the Medicaid legislation. The ASSA executive director and officers will stay tuned in to any movement of the legislation through either state house or any changes to the current form of the legislation.

Drs. Trey and William Ware and Fran Boyette at the ASA Annual Meeting.

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FAQs on Medicaid “Transformation” Alabama’s Medicaid program is on its way to being fundamentally transformed from a fee-for-service model to managed care model of care delivery. But instead of contracting with commercial managed care organizations to deliver care to Medicaid beneficiaries, the state is allowing the creation of locally-run regional care organizations (RCOs) to coordinate care delivery.

While ROTUNDA has chronicled the main portions of the Medicaid “transformation” over the course of the session, as the legislation – now law – begins to be implemented, the Medical Association will provide you with more in-depth details. While some things about the transformation are known and certain, many rules and regulations must still be drafted and adopted before the first patient is seen under the new delivery mechanism.

MASA will keep you posted on all new information and developments on the road to Medicaid “transformation.”

Below is a list of frequently asked questions on the legislation, SB 340, which is the vehicle that will enable the transformation of Alabama’s Medicaid program.

Q: WHAT IS AN “RCO?” A: RCO stands for “regional care organization,” an organized group of physicians, hospitals and other providers of Medicaid services in a group of counties in the state. The organization could be a limited liability corporation or a for-profit or some other type organization, but those participating in the organization will contract with the state to provide care to all Medicaid patients in that region. Each RCO contracting with Medicaid to deliver care in its respective region must be approved by the Medicaid Agency. Each RCO will provide services to Medicaid beneficiaries either through the RCO or through contracts with other entities. An RCO must contract with any physician, hospital or other provider willing to accept the payments and terms offered to comparable providers.

Eventually, RCOs will become risk-bearing entities.

Medicaid will collect and publish information (unless protected by law) regarding quality, cost and outcomes for each RCO. RCOs must meet minimum solvency requirements for operation or submit proof of a bond guaranty in an equal amount of the solvency requirements to the Medicaid Agency as one of the requirements for approval as an RCO for a region. Each RCO will also have to issue periodic reports, financial and otherwise, to Medicaid.

All data reported to Medicaid shall be consistent with HIPAA requirements. Medicaid will also conduct audits of each RCO at least every three years. At intervals, each RCO will be evaluated by Medicaid to determine whether the Agency will enter into a continuing contract for care delivery by that RCO for the region it serves.

Q: HOW WILL THESE “REGIONS” FOR CARE DELIVERY BE SET UP? A: The state will be carved up into care regions, which Medicaid will ensure are actuarially sound. While it will be up to the Medicaid Agency to determine the number of regions and their geographic boundaries, the state will likely end up with between 5 and 10 regions. Each of these regions must be capable of supporting at least two RCOs that agree to provide a comprehensive package of Medicaid benefits to Medicaid beneficiaries in a defined region of the state. Medicaid beneficiaries will be assigned and enrolled to a care region by Medicaid, and those falling within a region with two RCOs will be given a choice or assigned to one.

Q: HOW WILL THE RCOs BE PUT TOGETHER AND HOW WILL THEY OPERATE? A: Physicians, hospitals and other entities providing healthcare services to Medicaid beneficiaries within each of the Medicaid actuarially-sound regions will have to come together and organize as RCOs, which are explicitly not considered insurance companies under the law. Each RCO shall have a medical director, who is a primary care physician, and a governing board of 20 members who fall into one of two categories: (1) 12 risk-bearing members, who contribute either capital, cash or other assets to the RCO, to include physicians or others providing healthcare services who agree to a capitated payment rate to treat beneficiaries; and, (2) 8 non-risk bearing members to include three primary care physicians, one optometrist, one pharmacist and three community representatives.

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For those members in category (2), two of the primary care physicians shall be appointed by a caucus of county boards of health in the region while the third shall be from a Federally Qualified Health Center. These physicians and the optometrist and pharmacist serving on the board must work in the region served by the RCO and they can be neither risk-bearing participants in the RCO nor an employee of a risk-bearing participant, but they can still contract with the RCO on a fee-for-service basis. The three community representatives in category (2) are a business person in the region and two representatives nominated from the region’s citizens’ advisory committee, made up of Medicaid beneficiaries and patient advocacy groups. No single type of healthcare service provider, whether physician or otherwise, may have a majority membership on the RCO board. Additionally, other safeguards exist to ensure physicians have a strong voice in decisions made by each RCO governing board.

Q: CAN COMMERCIAL MANAGED CARE RUN ONE OF THESE REGIONS? A: While an RCO may contract with an alternate care provider or commercial managed care company, only under certain limited circumstances may such an entity be allowed to fully manage delivery of healthcare services in a region. Those circumstances include the failure or termination of an RCO in the region; the lack of an RCO or any other organization in the region willing to accept management of care delivery for the region; and, the lack of any other established or probationary RCO elsewhere in the state willing to attempt establishing an RCO in the region in question. Any alternate care provider or commercial managed care company that contracts with Medicaid to provide healthcare services in a region shall be subject to the same network adequacy requirements as an RCO.

Q: IF WE’RE MOVING AWAY FROM FEE-FOR-SERVICE, HOW WILL PAYMENT RATES BE DETERMINED? A: Medicaid will determine the capitated payment rate per-beneficiary to the RCOs. The governing board of each RCO will then determine how to apportion that payment amongst physicians and others providing healthcare services within the RCO, for both fee-for-service and at-risk contracts. Some physicians will elect to continue seeing Medicaid patients on a fee-for-service basis, such as those in category (2) of the RCO governing board. For those electing to enter into a “risk-reward” contract with an RCO, the “risk” is the capitated payment per beneficiary. If quality care is provided to patients for less than the capitated amount, those participating as at-risks physicians will share in the “reward” of those savings. This is the reason for the solvency requirements for each RCO – if the cost of care exceeds the capitated amount, the RCO’s reserve can be accessed to cover the cost of that care. In Alabama’s Medicaid “transformation,” the financial risk of caring for patients shifts from the state to each RCO for the patients served in that region.

Q: ARE THERE ANTI-TRUST CONCERNS FOR PHYSICIANS? A: The legislation specifically addresses that concern to provide safeguards for physicians. Because physicians, hospitals and others participating in the RCOs will be collectively negotiating and bargaining with one another to establish payment models for care delivery, the Medicaid Agency will play a direct supervisory role in that process to ensure protection from federal and state anti-trust laws. Physicians wishing to collectively participate will need to receive a certificate from the Medicaid Agency in order to collaborate with other entities, individuals or RCOs.

Q: HOW WILL QUALITY STANDARDS BE ESTABLISHED? A: Medicaid will establish a Quality Assurance Committee appointed by the commissioner. At least 60 percent of those on the committee will be physicians who participate in one or more RCOs in the state. The committee will assess outcome and quality measures for all services provided to Medicaid beneficiaries, and all measures must be consistent with state and federal quality guidelines.

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FAQs on Medicaid “Transformation” (continued from page 9)

Q: HOW WILL CLAIMS REJECTIONS AND GRIEVANCES BE HANDLED? A: Medicaid will establish a timely procedure for wrongful denial of claims and develop rules for the appeals process for this and for addressing grievances of Medicaid beneficiaries. The first step for rectifying the purported wrongful denial of a claim will be an immediate appeal to the RCO’s medical director, whose decision shall be binding on the RCO. If the physician or patient filing the initial appeal is dissatisfied with the medical director’s decision, an appeal may be filed for a hearing before a peer review committee composed of three RCO-participating physicians of the same specialty practicing within the region. If the physician or patient filing the initial appeal is dissatisfied with the peer review committee’s decision, an appeal may be filed with the Medicaid Agency. If the physician or patient filing the initial appeal is dissatisfied with the Medicaid Agency’s decision, the physician or patient may file an appeal in circuit court.

Q: WHAT IS THE TIMELINE FOR IMPLEMENTATION OF THE TRANSFORMATION? A: By October 1, 2013, Medicaid must have the care regions established. By October 1, 2014, an organization seeking to become an RCO must establish a governing board and structure approved by Medicaid. By April 1, 2015, an organization with probationary RCO status must demonstrate to Medicaid the ability to establish an adequate medical service delivery network. By October 1, 2015, an organization that has received probationary RCO status must demonstrate to Medicaid that it has met the solvency/financial requirements. By October 1, 2016, an organization with probationary RCO status must demonstrate to Medicaid that it is capable of providing services in the region pursuant to a risk contract. Nothing shall prevent an organization seeking Medicaid approval to operate as an RCO from meeting any of the aforementioned deadlines at an earlier date.

Q: WILL THIS SOLVE THE PERPETUAL MEDICAID FUNDING CRISIS? A: Unfortunately, no. The current Medicaid budget utilizes roughly 30 percent of the State General Fund, which also funds corrections and most non-education state spending. The current economic slump the state and nation are in has caused the Medicaid rolls in Alabama to increase by about 200,000 people since 2008 when the recession began. State lawmakers are hopeful the transformation from fee-for-service to RCO-run managed care will improve outcomes and reduce future growth in the General Fund budget. *Article Reprinted from MASA with Permission Alabama’s Federal Health Insurance Exchange (continued from page 4) States that establish their own exchanges, for example, can decide which insurers participate and whether to require benefits beyond those set under federal law. They can accept all insurers whose policies meet the law’s requirements, for instance, or limit participation by requiring that insurers meet specific quality or pricing guidelines. In Alabama, there are about 15 separate insurance products, 13 of which are administered by Blue Cross Blue Shield of Alabama. So your guess is as good as mine whether other insurance companies will be allowed to compete. Some exchanges and state insurance commissioners will be able to recommend whether specific insurers should be allowed to sell in the exchange, partly based on their patterns of rate increases.

Whatever the Federal Insurance Exchange looks like in Alabama, one thing is certain; it’s expensive. Obama’s budget requested $1.5 billion to run the exchanges in the 26 states that have opted for the Federal Exchange.

The law provided generous subsidies to states that set up exchanges, and it was widely assumed most states would do that. But when so many opted instead to let the federal government establish the marketplace, many advocacy groups expressed concern that the law did not provide adequate resources. So what happens if Congress does not give HHS the money it wants for exchange implementation in fiscal 2014?

Clearly, we have many questions regarding the implementation of the Federal Insurance Exchange in Alabama, and this article gives a thumb nail sketch of how it may look.

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ASSA Lobbying Fund The ASSA depends on the contributions to its “Lobbying Fund” to help address issues on the state level. Such activity has included legislative involvement, practice expense surveys and prospectively it appears as if we will need financial assistance to address several legal items as they relate to scope of practice and the new developments resulting from PPACA, such as ACOs. Additionally, it provides assistance with travel related expenses so that any ASSA member who wants to go to D.C. and advocate on behalf of anesthesiology may do so without suffering a large financial outlay. Our continued advocacy is vital!

Similar to our requests for contributions to ASAPAC, the Lobbying Fund is not required for membership but it is imperative for the livelihood of our specialty.

The healthcare landscape is vastly changing, and the changes are drastic. To those who want to have an impact and a voice in these changes, we thank you for once again putting your hard earned dollars into our efforts. It is an investment that we believe has a large return on investment whether you are in the academic or the private sector. And as anesthesiologists, we are known to be actively engaged until the bitter end; we are fighters and survivors! To those who contributed this year (see list below) we thank you for not allowing “contributor fatigue” to discourage you from helping in our efforts. To those who elected to “sit out,” we hope you will reconsider your decision and participate. Collectively we do make a difference and we need everyone to come together now more than ever as we navigate many changing landscapes.

2012-13 ASSA Lobbying Fund Contributors Montgomery Anesthesia Associates Fran Boyette, $1,000 Tim Doles, $1,000 Nancy Haring, $1,000 Bill Jordan, $1,000 Susan Kreher, $1,000 Rene Llera, $1,000 Kevin Pace, $1,000 Dana Williams, $1,000 100% Contribution rate

West Alabama Anesthesia Lee Carter, $500 Fred Rock, $500 David Verzino, $500 100% Contribution rate Individuals Gene Gordon, $500 Phil Hanlon, $500

Ambulatory Anesthesiology & Pain Medicine Tom Cash, $500 John Shearer, $500 100% Contribution rate

Anesthesia Services Birmingham Michael Barlow, $500 Kevin Bevis, $500 John Bullington, $500 Joseph Clay, $500 Kim Conner, $500 Anthony Cook, $500 Nelson Cooper, $500 Paul Elliott, $500 William Fitzpatrick, $500 Ed Kezar, $500 Matthew Kimball, $500 Wayne Lewis, $500 Lajuana Logan, $500 Paul Nagrodzki, $500 Jim Rudulph, $500 Abe Schuster, $500 Daniel Sherrer, $500 100% Contribution rate

Anesthesia Medical Consultants Bill Blackburn, $500 Suzy Blaylock, $500 Mike Gosney, $500 Neal Jeter, $500 100% Contribution rate

UAB Dept. of Anesthesiology William Baker, $500 Pete Hendricks, $500 Tom Moore, $500 Blair Smith, $500 Pam Varner, $1,000

Ambulatory Anesthesia Assoc. of Montgomery Jack Anderson, $1,000 William Ware, $500 100% Contribution rate

Pediatric Anesthesia Associates (Children’s) Jenny Dollar, $500

Alabama Anesthesia of Huntsville Tim Adams, $500 Reid Fletcher, $250 Murali Gadde, $500 Bill Hass, $500 Chi Kwok, $125/month, $1,500 John Panico, $500 Wendy Seaver, $500 Comprehensive Anesthesia Services Michael Muller, $1,000

Anesthesia Consultants Medical Group Bayer Cheng, $500 Ralph Fillmore, $500 Lewis Hunt, $500

Kelly Hyde, $500 Brit Lovvorn, $500 Philip McClarty, $500 Craig Nordhues, $500 Jeff Plagenhoef, $500 Vernon Pruitt, $500 Puli Reddy, $500 Steven Sykes, $500 Ty Warren, $500 Michael Weatherford, $500 James York, $500 100% Contribution rate Southern Perioperative David Kraftsow, $500 Ben Walker, $500 Anesthesia Services of Mobile John Alexander, $500 Jon Botts, $500 Ron Brown, $500 Donald Butts, $500 James Daniell, $500 Donna Dark-Mezick, $250 Bulent Erdemir, $500 Robert Hannahan, $500 Jerry Hennig, $500 Ron Jordan, $500 Mike Lasecki, $500 Eric Lobel, $500 Lawrence Morgese, $500 Ryan Neil, $250 Don Richerson, $500 Anthony Savoie, $500 Franklin Trent, $500 100% Contribution rate Eastern Shore Tim Houseman, $500 Teresa Kelly, $100 Blake Neal, $500 Bill Womack, $500 Anesthesia Associates of Gadsden Richard Gallo, $2000

11

ASSA

P.O. Box 241453 Montgomery, AL 36124

New Website The ASSA has a new website and a new web address: www.theassa.com The new features are more user friendly and will allow for online payments of membership dues, as well as contributions for political purposes. We will also be “going green,� which means we will cease the print version of our quarterly Newsletter. Please go to the site, register and make certain to sign up to receive your electronic version of future Newsletters.

www.theassa.com