No end in sight to
shortage of
anesthesiologists

Low reimbursement rates alienate
anesthesiologists, cost patients

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By Lyn Danninger
Star-Bulletin

For a year, Dr. Sam Schomaker was an anesthesiologist in Kona. For several months, he was the only one, required to handle any surgery, day or night.

With no help forthcoming and the hours piling on, he quit.

"When I first started there were three other anesthesiologists," he said. "Eventually, I was the only one. I wound up on call 24 hours a day, seven days a week. It took a toll."

Schomaker eventually chose academia over anesthesiology. He is now the vice dean of academic affairs at the University of Hawaii's John A. Burns School of Medicine.

His experience is becoming common in rural areas, contributing to a nationwide shortage of anesthesiologists. Operating rooms across Hawaii are backing up elective surgeries and rearranging operating schedules into the night so an anesthesiologist is available.

The shortage was recently complicated when the state's largest anesthesia specialty group, The Anesthesia Medical Group Inc., employing 30 anesthesiologists, decided it would no longer participate with the state's biggest insurer, Hawaii Medical Service Association. The group cited inadequate reimbursements, particularly from HMSA's most popular preferred provider plan, as the major reason for the decision.

They also say they can't recruit or retain anesthesiologists, especially those assigned to neighbor islands, given exhaustive working conditions and inadequate reimbursements.

The consequences are felt in areas such as the Big Island and Maui. No anesthesiologists participate with the state's largest health insurer in Hilo, and only one participates on Maui on a limited basis. Patients insured through HMSA have the choice to fly to Oahu for surgery or pay higher anesthesiology bills from non-participating doctors.

If more anesthesiologists can't be found, the state Legislature may get involved, said David Matsuura, chairman of the Senate Health and Human Services Committee.

There are no easy answers, he said. And it has the potential to impact the entire state health system, Matsuura said.

The lack of participating anesthesiologists could harm the revenues of the state's neighbor island hospitals, Matsuura said. Much of their revenue depends on income derived from surgeries performed there, he said.

"If we lose our (neighbor island) patients to Oahu private hospitals, we'll pay for it again there," he said.

The state Insurance Division has also been following the issue, particularly as it relates to the anesthesiology group's decision to not participate with HMSA, but Insurance Commissioner Wayne Metcalf said his department has no power to intervene.

With already tight surgery schedules as anesthesiologists take vacations during the summer months, even Oahu may not be guaranteed as a timely alternative for elective surgeries.

Schomaker said the national shortage of anesthesiologists began after a 1994 national study concluded there would be a future oversupply of anesthesiologists. At the same time, the Clinton administration started discussions of large-scale health reform. Many also thought Medicare would lift restrictions that require anesthesiologists to oversee nurses administering anesthesia, opening the door for increased use of the nurses.

Most insurance carriers, malpractice insurers and the federal Medicare and Medicaid programs still have strict rules about physician supervision of nurse anesthetists during surgery. Anesthesiologists have traditionally supervised and many surgeons are leary of that role, they say.

While replacing anesthesiologists with nurse anesthetists has been floated as a potential remedy for short-staffed rural areas, Schomaker and Matsuura say it's not an option, largely for reasons of liability. Moreover, there is also a nationwide shortage of nurse anesthetists.

Even though the federal health care reform plan never got off the ground, medical school deans discouraged graduating students from pursuing specialties in anesthesiology and the number of graduate medical programs available for anesthesiology declined sharply, Schomaker said.

At the University of Hawaii, there is no anesthesiology residency program. Last year, only one student of 51 chose to specialize in anesthesia.

There is little likelihood that an anesthesia residency program could be developed at UH, Schomaker said.

He said unless positions could be re-allocated from other residencies such as obstetrics, family practice, surgery and pediatrics -- programs supported by federal dollars and local hospitals -- it would be difficult to create an anesthesia residency program.

"We talked about the need to start an anesthesia residency but it's very expensive and you can't get Medicare reimbursement for it," he said. "We'd be happy to start a program, but just don't have the money to do it."

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Low reimbursement rates alienate
anesthesiologists, cost patients

This chart shows what insurance carriers pay members of The Anesthesia Medical Group Inc. for three types of surgeries, along with the amount billed for the service. Payments between insurers and physicians may be more or less, depending on contracts.

With the exception of some mainland-based commercial insurance plans, such as Aetna and United Health Care, which reimburse at higher levels, most insurers usually require a member co-payment of up to 20 percent of what the insurer pays. When a physician or hospital no longer has a contractual relationship with an insurer, the patient is generally responsible for the balance not covered by insurance.

Procedure	Breast biopsy	Knee arthroscopy	Open heart surgery
Total bill	$580	$650	$2,835
Reimbursement rates
Medicare (nonparticipating)	$150.40	$168.50	$733.86
HMSA	$160.19	$179.50	781.65
HMSA	$228.75	$256.31	$1,116.81
AlohaCare (Quest)	$236.55	$265.05	$1,154.25
UHA	$290.50	$325.50	$1,417.50
HMAA	$265.60	$297.60	$1,296