TSA President's Acceptance Speech

It is with tremendous humility and a sense of gratitude that I assume the role of Presidency of the Texas Society of Anesthesiologists

It is a great honor to follow in the footsteps of Dr. George Williams II, whose dynamic and overachieving term as President indeed leaves some very big shoes to fill!! I would consider myself as having succeeded in my term by next year if I could accomplish a fraction of what he did during this year. By our regular monthly phone calls and briefings, and with your gracious and friendly smile you have made my transition into this role so much easier and seamless. And for that, George, I am extremely thankful to you. I recommend that this House recognize the tremendous service rendered by Dr. George Williams this past year.

At the outset, I must point out that my reaching this point in leadership would not have been possible without the patience and the selfless-sacrifice from my wife and proud partner in my family – Menaca Padakandla. I was only able to make these numerous trips to Austin and Washington, DC for advocacy because of her gracious commitment to be a single parent to our three wonderful kids in my absence, driving them to their music lessons and softball and soccer sessions. For that I will always be indebted to you.
And I must also pay due credit to all the people in the Society who inspired me, taken me under their wings, and encouraged my participation in committee meetings and promoted my journey through the leadership ladder. My mentor in particular, Dr. Tillmann Hein deserves a special mention. I am forever grateful to you, Till!
The state of the Texas Society of Anesthesiologists is strong. It is vibrant, and brimming with energy and enthusiasm, and our society is well represented in legislative and regulatory circles of government in Austin. Dr. Tom Oliverson is the elected representative in the State Legislature. Dr. Sherif Zaafran was just reappointed the President of Texas State Medical Board. He is also a member on the Board of Federation of State Medical Boards.  Dr. Ray Callas has just been reappointed to the Texas Commission on Licensing and Regulation. Dr. John Scott is on the Board of Regents at the University of North Texas while Dr. Zach Jones is a member of the District 2 Review Committee of the Texas Medical Board, all four Governor appointed positions. Congratulations to all four of them!
TSA is also well represented at the American Society of Anesthesiologists (ASA). Texas has a long line of Past Presidents including Drs. Jim Arens, John Zerwas, Jeff Plagenhoef and Mary Dale Peterson. Dr. Pat Giam is currently Speaker of ASA House of Delegates and  in line to become ASA President soon. Dr. Scott Kercheville is the current Director for the ASA Delegation. We have some good news to share! Dr Crystal Wright was elected Assistant Treasurer of ASA last year  and Dr. George Williams is now the new Alternate Director. Congratulations Dr. Wright and Dr. Williams!

Advocacy

Advocacy is a very important aspect of our professional life. Plato in ancient Greece said,
“One of the penalties for refusing to participate in politics is that you end up being governed by your inferiors”.
If we don’t participate in the legislative and political sausage-making in Federal and State legislatures, the others are too happy to do that for us. If you are a newcomer to this House and/or the Society, I would ask that you approach the Chairs and members of Key Contact committee and TSAPAC Board and have a friendly conversation with them. Learn from them on how they can inspire you and how you can help the society. One other very effective way is to seek a mentor in your geographic area. Mentorship is a well-trodden path and a great welcoming way to feel that you belong here. Here are three things you can do for advocacy: a) volunteer for State Capitol visits b) make contacts with your local legislators and c) contribute generously to TSA and ASAPACs regardless of your ability to attend 
Capitol visits.
TSA works in close association with Texas Medical Association (TMA). Though there can be instances where TMA represents ALL Texas physicians and TSA can be at cross-purposes, for the most part the two Associations agree over the proposed legislation. We have a very robust section of TSA membership that are actively involved in TMA. In fact, our very own Dr. Ray Callas is the President-Elect of TMA! Congratulations Dr. Callas and we are very proud of your accomplishment!

Governmental Affairs Committee

As we successfully emerge from the 88th Texas Legislative session, I would like to take a moment to look at the issues at stake for this Society for the year ahead. I will mention several dark clouds that prevail over the legislature at any given time, not so much to intimidate the young and the inexperienced in this audience, but rather to invigorate them and help focus their energy on the tasks ahead. In the non-legislative year, regulatory work still goes on unimpeded, and the dark disruptive forces are always at work, trying to thwart our progress.
The Governmental Affairs Committee (GAC) directed by Ms. Elizabeth Farley and Ms. Jasmine Owen and assisted by our lobbyists Craig Chick and Michael Warner went into the 88th legislative session with a proactive agenda and offensive approach.
The four TSA priority bills were HB 3359 by Rep. Greg Bonnen, MD – Network Adequacy, HB 3098 by Rep. Ann Johnson – Anti-Vertical Integration, HB 2324 by Rep. Steve Allison – Title Misappropriation and HB 1700 by Rep. Jacey Jetton – Nursing Profiles on the Nursing Board Website. We also opposed multiple bills aimed at expanding the scope of practice of mid-level providers which would harm Texas patients.
TSA’s top priority, HB 3359 – Network Adequacy, passed the legislature and goes into effect on September 1, 2023. The bill addresses inadequate networks provided by health plans. A coalition of stakeholders including TMA, the medical specialties, the Texas Department of Insurance (TDI) and the health plans worked through the interim and during session to agree on language that would codify minimum standards for network adequacy compliance, limit network adequacy waiver requests and renewals by plans, add transparency to the waiver process by requiring public hearings, and establishing contract protections for physicians against mid-term 
contract terminations.
TSA’s other priority legislation did not become law this session but did start necessary conversations with lawmakers and their staff to consider during the interim and bring back up next session.
The scope of practice battle firmly remains in place. TSA was successful in protecting physician-led care, opposing bills that expanded the scope of mid-level providers in several ways. Those bills included HB 4071/SB 1700 – omnibus scope expansion bill; HB 1190 – delegation of prescriptive authority of Schedule II controlled substances to physician assistants (PAs) and advanced practice registered nurses (APRNs); and HB 4404 – APRN 
licensure compact.
Another defensive fight was preventing anesthesia services from being wrapped into value-based care – HB 1073. We also blocked legislation that would have allowed health plans to rank and tier physicians in a non-transparent way – HB 2414.
TSA supported HB 852 by Rep. Shawn Thierry, which adds greater physician representation of different medical specialties to the Texas Maternal Mortality and Morbidity Review Committee (MMMRC).
Prior to the session, TSA members proposed several ideas for bills that were discussed during the GAC meetings but ultimately were not drafted into proposed legislation. One such conversation was started by Dr. John Scott regarding unfunded trauma care.  Dr. Scott proposed legislation to ensure physicians providing care to unfunded patients are compensated if the hospital receives funds from the state for unfunded trauma. While legislation addressing unfunded trauma care was not determined to be a viable legislative priority for this session, significant progress was made.
TSA was able to get a rider in the state budget directing the Health and Human Services Commission (HHSC) to look at money for unfunded trauma care sent to hospitals in relation to payments received by physicians who are providing such care.
There is one other small but significant update from GAC. This one is from Dr. Jeremie Perry who sits on the Texas Medical Disclosure Panel (TMDP) that regulates the anesthesia consent form in Texas. Starting in September, the new anesthesia consent form will be enacted.  An important component is a section for “Non-Anesthesiologist Physicians” to be named.  Take this opportunity to have your Chief of Anesthesiology approach your facility to tell them about the new form. Any delegating Non-Anesthesiologist Physician needs to be named on the ANESTHESIA consent in 
addition to the surgical consent. This will ensure that Gastroenterologists, Cardiologists, Pain Physicians, and others who supervise/delegate anesthesia directly to a nurse or CRNA are in fact liable for anesthesia.

TSA Digital Ad campaign

In early 2023, working with ASA’s PR partner firm Reingold, TSA launched a digital ad campaign that helped us reach our target audience (legislators) and amplify our message. Our campaign included geofencing. We created social media and website display ads that were tailored to the interests and demographics of Texas legislators. By the end of the campaign, we saw impressive results. Our ads were seen more than 2.2 million times and garnered nearly 12,000 clicks to the TSA website. Our campaign was both effective and efficient.
TSA was very fortunate to have two Resident Scholars join the lobby team this session. TSA President Dr. George Williams implemented a one-month policy rotation modeled on the American Society of Anesthesiologists (ASA) policy rotation. Drs. Katharine Heffner and Nick Glenesk not only lived up to their expectations but exceeded them! Dr. Glenesk has joined a private practice group in Dallas and is already on course to become an active advocate for TSA! Dr. Heffner has moved to another state, and we will be sure to run into her at the ASA legislative conferences. Don’t be surprised to see Drs. Glenesk and Heffner rising through state leadership and ASA ranks in the next 5-10 years!!
We have many things to celebrate and many things to continue to work on as we approach the next legislative session. Topics that have loosely been identified as issues to work on include value-based care and unfunded trauma care, as well as the three bills we filed which did not pass. I am also tasking GAC with exploring ways to increase Graduate Medical Education (GME) funding to create more residency slots in the state of Texas.
The interim year will be focused on developing offensive ways to protect physician-led care and a plan of action regarding value-based care proposals we faced this session and shifting the mindset of key legislators to promote physician-run medical groups and competitive policies that do not favor vertically integrated health insurance companies.
Also, do not forget to follow TSA on social media at @TSAPhysicians and @GovtAffairsTsa on Twitter, and on Instagram. Thanks to our Social Media Associate Ms. Claire Foster!

Out Of Network (OON) billing issues

The question of dispute resolutions with insurance carriers, i.e., Independent Dispute Resolutions (IDR) process aka SB 1264 at the State level and No Surprises Act (NSA) at the Federal level have taken center stage in the last several years.
SB 1264 applies to health plans regulated by TDI and people with coverage through the state employee or teacher retirement systems – or about 20% of Texans. It creates two distinct billing dispute resolution processes – arbitration for physicians and other providers and mediation for facilities and labs. Based on the last Biennial Report published in November 2022, from January 2020 to June 2022, the Texas Department of Insurance (TDI) received 306,149 requests for arbitration and mediation, of which 262,175 were eligible, through the IDR portal. In-network participation rate for anesthesiologists has stayed stable around 80% throughout this period, compared to 96% for hospitals and 40-47% for ER physicians. Median Arbitrators fee was $1257, ranging from $350 to $5,000. A total of $75.7 million (5.8% of total) was paid as arbitrator fees for a total resolution of more than $1.3 billion in medical billing disputes.
From the most recent data from the Federal Government, IDR entities have resolved only about one-third of disputes submitted between April 2022 and March 2023. There were 334,828 disputes initiated through the Federal IDR portal, about 14 times greater than what the Departments had initially anticipated. Nearly 40,000 of the disputes were deemed ineligible. IDR entities rendered payment determinations in 42,158 disputes through the end of March. That leaves roughly 250,000 disputes unresolved as of the end of the period. No doubt insurers are incorporating these delays into their ongoing strategies to starve physician practices. Of the disputes resolved, 71% are in favor of the providers. The administrative fee, raised from $50 to $350, however, remains a serious barrier to true access to arbitration, as it renders the arbitration of smaller claims financially unviable. There is a litany of other ongoing problems: 1) the bogus insurer calculated QPAs/initial payments that force practices into dispute resolution, 2) overly restrictive batching rules, 3) delayed payments from insurers to physicians who prevail in the arbitration process, and 4) a full range of other areas 
needing attention.
Now I want to turn your attention to the internal matters of the Texas Society of Anesthesiologists.
First, Tina Haggard, who has been the webmaster for TSA’s online presence for the last many years has indicated her desire to retire but has agreed to stay in her job till we find a suitable replacement. Among the many services Tina provides through her Fingertek company, she maintains the TSA membership database and its administration, TSA’s website- the public face of the Society- its content management and site administration, managing the Stripe payment processing system for both TSA and TSAPAC (including dues payments and meeting registrations for TSA, and all donations for TSAPAC), administration of TSA and TSA Governmental Affairs email accounts and email discussion lists, and publication of TSA annual meeting brochures, two semi-annual newsletters, the HOD handbook, and 
meeting presentations.
Before proceeding further, I recommend that we take a moment to recognize Tina Haggard for her many years of commitment and service to this Society. Thank you, Tina.
Next, I would like to continue the Ad-Hoc Committee already in place to search for and recommend a web-hosting company to provide all those services that I outlined above, and more. The current Committee will add two additional members: one each from the Finance Advisory committee and TSAPAC Board. The needs and expectations for the online presence of this Society have expanded considerably in the last 30 years. While the current website has done well to meet our needs, this Society needs a more robust, versatile, scalable database AND website administration company. The recommendations from the ad-hoc committee will be vetted by the Administrative Affairs committee, and the final candidate hosting company will need to be approved by the Board. I am asking this Ad-Hoc committee to submit a report on the status on their task at the January 
2024 Board meeting.
Letting ASA host the Website and the database needs to be considered as one of the options, based on information presented at the ASA August Board meeting. Finally, in anticipation of the transition to a larger database and website hosting company, I recommend allocation of $25,000 from the Reserve Funds.
Last but not the least, I want to focus on the committees and their appointments. If you are new to this society, you may want to know that most of the work of this society is carried out through the various committees. Different committees are charged with different tasks and the volunteers on these committees focus all their energy on the task in front of them and come up with excellent resolutions and brilliant ideas.

I want to take a moment here and congratulate the chairs of the specific committees for the most extraordinary work they have done in the past year. Dr. Anna Allred did a tremendous job being the chair of the Governmental Affairs Committee. I already have provided the accomplishments of the GAC a minute ago. Dr. John Scott has done a fabulous job as chair of TSAPAC. Under his leadership with help from Ms. Elizabeth Farley and Ms. Jasmine Owen, the committee has garnered the most money raised from voluntary contributors this past year. The Education Committee chaired by Dr. Vijaya Gottumukkala has done an outstanding job by arranging last years and this year’s CME sessions which are truly of international standard. The Communications Committee led by Dr. Chris Cook was instrumental in kicking off TSA’s Digital Ad campaign so effectively reaching dozens of legislators and their staffers. Dr. Russell McAllister, Chair of the Editorial Board, has done a fantastic job with the publication of twice-yearly Newsletter that keeps members informed on what is going on inside the Society. I recommend that these leaders 
be recognized for their hard work 
and dedication.

Each standing committee is required to hold a meeting at least once a year in person or virtually and submit a report to the House of Delegates annual meeting. The Committee on Meetings, established in 2015, was charged with   identifying membership educational needs and guiding the content of the sponsored meetings accordingly. A committee that lacks any activity in several years has outlived its purpose and is no longer needed. I recommend that the Committee on Meetings be dissolved by the 
House of Delegates.
In as much as I would have liked to preserve the current composition of the various committees, I couldn’t help but notice that several committees have 2-3 times the required number of members specified in our Bylaws. Meeting space suitable to accommodate the large committees and non-members can be a challenge at some of our meeting sites. We also have members serving on numerous committees and these members find themselves having to choose which committee meeting they will miss, to attend another which may have items that are of greater interest to them.
We must be looking out for vetting and mentoring new or newer members of the Society for future leadership roles. As one of the Past Presidents Dr. Jeff Jekot said, “Some of you are future leaders of this Society here in this House and you do not yet know that”. There are several leaders who have very graciously yielded their position on some of these committees to give younger leadership a chance to rise. Dr. Jekot himself is one such leader living up to his words. Thank you, Dr. Jekot!
Staying on the theme of senior leadership for one more second, I would like to reflect on another action. I plan to appoint an ad-hoc committee to initiate discussion and explore the concept of term limits for participation in these committees. This is not a new concept. Texas Medical Association has clearly defined term-limits for its members on the various committees and Councils. And yes, that would entail a change of Bylaws. I expect the ad-hoc committee to present a report on its activities at the next year’s 
Annual meeting.
My sincere thanks to all the members serving on various committees for their hard work in advancing the cause of this Society. It is because of this hard work that TSA today stands high among professional societies as one of the best, if not THE best physician advocacy society! I recommend that the House of Delegates approve the Committee Chairs and Committee appointments in the list attached to this report.
Our residents and the medical students are the future of this Society. Exposing them early to advocacy alongside education is the best way to engage them. A comprehensive education plan for our young doctors-in-training should include clinical healthcare, healthcare economics and healthcare advocacy. I urge the residency program directors in Texas and the members on the Resident and Medical Student Education Committee to plan their educational sessions along these lines to maximize the return on investment of time, space, and money at Annual meetings.

That TSA is a well-oiled machine is a very well-known fact in the government leadership and political circles in Austin

And the way these annual meetings are organized and carried out so smoothly, is a thing to be proud of. The credit for bringing all this about goes to three distinct but well-coordinated facets of this Society:

  1. Executive Director Chris Bacak and her dedicated staff members Executive Associates Judy Garcia-Bigger, Jessica Shepherd and Social Media Associate Claire Foster.
  2. Governmental Affairs Director Elizabeth Farley and her Associate Jasmine Owen.
  3. Our wise Counsel Clayton Devin.

I recommend that these ladies and the gentleman be duly recognized for the valuable role they play in keeping this Society vibrant and strong.

UDAYA BHASKAR PADAKANDLA, MD  
President 2023-2024

president@tsa.org

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