I am amazed that I am not finding alot of discussion about the effect of Healthcare reform on the profession of Anesthesiology.    Under the current proposal based on the payment of Medicare reimbursement to physicians, anesthesiologists will be reimbursed at around 30% of private insurance rates.  Further, Mr. Orzak, Mr Obamas budget director stated that future legislation will include a further across the board 20% cut in physician reimbursements.  Further, don't expect that hospitals or private insurance to prop up reimbursements, since the public option paying medicare rates will quickly force private insurers and hospitals to drop their payments to Anesthesiologists to stay in business. 

I do not think the profession of anesthesiology can survive a 60% cut in payments.  Anesthesiology residencies cannot afford to operate, and virtually all anesthesia will be provided by CRNAs.   However even CRNA training programs will be squeezed by such drastic drops in reimbursements. 

Personally, I am so frustrated with what is happening that I will probably retire shortly after any such changes occur, and I will stop being a producer, and try to live off the government as much as possible.  What is the motivation anymore to work?  I may do free care in medical missions. 

My question relates to billing for TIVA (total IV Anesthesia) for cases which I have always billed as MAC (monitored anesthesia care).  In reality I do often believe that a significant percentage of patients do slip into deep sedation or perhaps deeper when I do such cases (endoscopies/I+D's), and perhaps even a state of general anesthesia on occassion.   

This question arises since I see that the CRNA's that work independently of me, charge for TIVA routinely.  This of course allows reimbursement for cases that if billed as MAC would not be reimbursed.  Up to this point, I have continued to bill as MAC, even when I know this will mean I am not reimbursed.  I am frustrated by the fact that the government would have such a payment system, and believe that the system encourages people to bill for TIVA.

I have worked the past 10 years as an anesthesiologist.  I trained at a respected U.S. medical school, completed a Ph.D. in pharmacology from the top program in the U.S., completed a anesthesiology residency and fellowship and stayed in academics for four years prior to entering private practice. 

My first five years of private practice was a dream come true.  I was well respected by both the administration of the hospital and the other physicians on staff, and I had a mutual respect for the other members of the staff.  Unfortunately, due to decreasing volume, the hospital ended up closing. 

In order to stay in the same city where my home was, the only nearby hospital was about 40 mins away in a rural area.  The administrator who recruited me was honest and supportive.  Unfortunately he retired 4 months after I started, and a new administrator came on who basically had one objective in mind-making money for the hospital.    We now are being asked to do elective cases at all hours with no free anesthesia personel available despite the fact that we have laboring patients and patients with running epidurals.  Additionally, although the majority of surgeons were not bad, I found that there were surgeons on staff that definitely had FAR more complications than I would expect.  Additionally one of the surgeons appeared to have an issue with power, and had mulitple conflicts with the CRNAs on staff.  After this surgeon basically chased off the CRNAs he now appears to be playing a power game with me.  He basically is attempting to dictate to me what labs I may or may not order.  The other surgeon  has attempted many times to pressue me to do clearly elective cases on full-stomach patients.  All of the surgeons have had multiple lawsuits in the past. 

In one case, the administrator came to talk to me about why I would not do  an elective case on a full-stomach patient.  She asked such questions such as "can't you just give a little sedation, or do a spinal so that you do not have to put them to sleep?"

I am beginning to feel as though I am constantly being pressured to ignore all the years of training and board-certification, in order to cater to surgeons that I personally would never go to.  I feel no support from the administration since they are interested in making the surgeons happy and increasing volume. 

I would further add that in the ten years of practice I have never been sued or faced any board or legal action.
I am by nature very easy going, and have never had any type of yelling match during any of these issues, but have been apologetic and explain why I do not feel comfortable doing something I feel is not safe. 

Have others faced this situation, and how have they dealt with it.