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ISA UPDATE NEWS FOR THE IOWA SOCIETY OF ANESTHESIOLOGISTS President’s Message Spring 2009 Issue changing our administrative staff to DMS we have been able to reinvigorate our web presence, improve the annual spring meeting, resurrect the fall meeting and build new relationships with our state legislators and the governor. Presently, our state PAC contributions are at an all-time high; something that has facilitated our legislative success. This trend must continue. I’d like to think that I met the goals of my administration and in the process enhanced the safety of Iowans and the professional security of ISA membership. Over the preceding two years we have successfully defeated a cut to our Medicaid reimbursement and actually garnered a 1.5% increase. Cumulatively, this preserved in excess of $3 million of revenue for our membership. We have actively fought against the CRNA practice of interventional pain management and at this time are on the brink of putting this issue to rest in Iowa. By As I pass the torch to Frank Cassady, Jr., M.D., our new ISA president, I am assured that our society is in good hands. Frank and I have enjoyed an excellent working relationship and have together implemented the successes of these past two years. You can expect more of the same during his term! Despite steep declines in state tax revenues, we are happy to report that there will be no cut in Iowa’s Medicaid reimbursement. This is in part thanks to substantial federal funds earmarked for this purpose. ISA officers and officials have also maintained an ongoing dialog this year with legislative leaders. We will continue to watch this issue closely and fight against any disproportionate decrease in fees to anesthesia providers. President Joseph F. Cassady, Jr., MD West Des Moines President-Elect Douglas G. Merrill, MD Iowa City It is with relief and melancholy that I write my last president’s message. Looking back, it has been an active and productive two years. I want to thank everyone that has made my term in office such a success; especially: my family and partners who gave me the time to serve, the executive committee and officers who provided good counsel and the administrative staff who’ve kept our society running smoothly. Iowa Legislative Update Officers Secretary/Treasurer Sherif H. Tewfik, MD Grimes Immediate Past President Patrick H. Allaire, MD Ames District Director John R. Moyers, MD Iowa City Asst. District Director James L. Becker, MD Waukee Patrick Allaire, MD ISA President In April, the Iowa Board of Medicine (IBM) ruled that chronic interventional pain management is indeed the practice of medicine. Attached, find a draft copy of this ruling. This ruling will set precedent and challenge any finding by the Board of Nursing (BON) that CRNAs are qualified to perform these procedures. The IBM finding is critical to any legislative or judicial challenge brought by the CRNAs; as it is unlikely that the courts or our 1 legislators will go against the finding of the IBM. ISA has been intensely involved in shepherding this ruling through the Board of Medicine. A special thanks goes out to Rick Rosenquist, M.D., Professor, U of I, for his counsel and expert testimony at the IBM hearings. ISA PAC ISA Spring Meeting ISA PAC distributed in excess of $24,000 to 47 state legislators during the past year. These funds are critical to maintaining and enhancing our legislators’ awareness of our issues at the state capital. Presently, we have about $11,000 in our PAC coffers. It is vital that each and every ISA member make an annual PAC contribution. The ISA spring meeting, held on April 4, at the Hotel Fort Des Moines was a huge success. A record number of both attendees and vendors were present. We were treated to world class lectures by Drs. Joy Hawkins, Randy Clark and Mark Warner. Dr. Warner’s participation represented the third consecutive year that an ASA Vice President has attended our meeting. Awards were presented to Dr. Trish Hoffman, outgoing IMS president and Dr. Jim Becker, Immediate Past-Chair of the ASA PAC Board of Directors, for their contributions to the anesthesia community. Considering the successes ISA has had in the past year at preserving and enhancing your incomes and protecting the specialty of anesthesiology from unqualified interlopers…the decision to make a contribution should be easy!! Enclosed, find a list of ISA-PAC donors and a contribution form. Mail yours today, so you don’t have to feel guilty the rest of the year. ISA Officer Changes Congratulations to the ISA officers newly elected at the spring meeting. Dr. Doug Merrill, U of I, became president-elect and Dr. Sherif Tewfik, Des Moines, was elected secretary-treasurer. Your ISA delegates and district directors remain unchanged. Thank-you to these excellent candidates for their willingness to serve in this volunteer capacity. Following the annual business meeting (minutes attached), the ISA PAC cocktail reception was very well attended and will be continued at future meetings. Take this opportunity to mark your calendars for our fall legislative update to be held in Iowa City on Sept. 14. Also, next years’ spring meeting will be held in West Des Moines at the Holiday Inn and Suites on April, 10, 2010. This property is easily accessible (only three blocks) from I-35 in West Des Moines and is close to the Jordan Creek Mall. Note that the venue is changed due to renovations that will be ongoing at the Hotel Fort Des Moines. Please make plans to attend and encourage your practice partners to do the same. Dr. Mark Warner, First Vice President of the ASA, presented a session focusing on Positioning Problems. Wellmark Denies Anesthesia Claims for GI Endoscopy In its recently published rules for participation, to take effect July 1, 2009, Wellmark has decided to deny anesthesia claims submitted for GI endoscopy, with only a few exceptions (see attached). This ruling has created an outcry from the anesthesia community. ISA opposes any third party intervention in the prescriptive decision making between patient and physician. For this reason, the ISA’s and ASA’s Presidents recently contacted Wellmark policymakers to express compelling concerns regarding public safety implications as well as Wellmark’s future to consider the right of Iowans to choose their own healthcare. Individual ISA members may also contact Wellmark directly to urge recision of the policy on these grounds. Dues Increase The fiscal realities of running an organization with multiple active legislative and professional issues requires that from time to time dues are adjusted to cover the cost of these battles. The last time a dues increase was sought was six years ago. In that time, we have enjoyed much success in the legislative arena, but at a significant financial cost. For the last three years, we have run deficits and drawn from our reserves to cover these costs (to the tune of $70,000). The board of directors is predicting continued deficits in the foreseeable future if we do not adjust our dues. Therefore, a $100 annual increase was sought and granted from the house of delegates at our annual meeting in April. Your dues will therefore increase from $300 to $400 beginning in January, 2010. A paltry sum considering that in 2007-08 the efforts of ISA and ASA enhanced the gross income of every anesthesiologist in the state by more than $28,000. 2 DRAFT POLICY * DRAFT POLICY * DRAFT POLICY * DRAFT POLICY The Board will discuss the policy statement and receive public comment about it on May 21. Written comments for the board are due by April 24 and should be mailed to Board Executive Director Mark Bowden, 400 S.W. Eighth Street, Suite C, Des Moines, IA 50309 or e-mailed to [email protected] Iowa Board of Medicine Policy on Chronic Interventional Pain Management Approved ___________ Definition Chronic interventional pain management, as defined by the National Uniform Claims Committee, is the diagnosis and treatment of pain-related disorders primarily with the application of interventional techniques in managing subacute, chronic, persistent, and intractable pain.1 Interventional pain techniques include percutaneous (through the skin) needle placement. Drugs are then placed in targeted areas, nerves are ablated (excised or amputated), or certain surgical procedures are performed. By way of example, procedures often involve injection of steroids, analgesics, and anesthetics and include: lumbar, thoracic, and cervical spine injections, intra-articular injection, intrathecal injections, epidural injections (both regular and transforaminal), facet injections, discography, vertebroplasty, kyphoplasty, nerve destruction, occipital nerve blocks, and lumbar sympathetic blocks. Interventional pain management may also include the use of fluoroscopy. Diagnosis and Treatment Chronic interventional pain management involves interactive procedures in which the physician is called upon to make continuing adjustments, noting that it is not the procedures themselves, but it’s the “the purpose and manner in which such procedures are utilized” that demand the ongoing application of direct and immediate medical judgment that constitutes the practice of medicine. These procedures are used to assess the cause of a patient’s chronic pain, as a therapeutic modality of treatment, and as a basis on which to recommend additional treatment, including the need for surgical intervention and repeated or additional treatments. Often times the pain physician will perform a different chronic interventional pain management procedure than prescribed by the referring physician based on the pathophysiology of the patient and the determination that a patient would be unable to withstand the prescribed procedure. In order to practice competent chronic interventional pain management the pain physician must understand the particular history of the patient, which includes a complete neurological, musculoskeletal and psychological assessment, as well as review of the available diagnostic studies (both preprocedure images and those obtained during the actual performance of the procedure). Only then can the pain physician develop a proper treatment plan which may or may not differ from the 1 Manchikanti, L. Medicare in interventional pain management: A critical analysis. Pain Physician. 2006;9: 171-197. referring physician’s order.2 Chronic interventional pain management requires constant medical diagnosis and judgment. Risks Interventional pain medicine carries serious risks: infections, brain damage, paralysis, or, even death.3 The assessment of risks of invasive procedures must always be taken into account. The performance of a “simple” epidural steroid injection, for example, for a herniated disk may be associated with a multitude of side effects and complications including weight gain, immune system suppression, spinal headache, nerve damage or even paralysis.4 Issues of concomitant administration of anticoagulants and the appropriate management of these when performing spinal or perispinal injections remains a paramount concern as well. Complications associated with performing these procedures without proper training arise not only from the procedures themselves, but from mismanagement of the patient as well.5 Allied health care practitioners, including certified registered nurse anesthetists, and others, do not possess the medical training or, therefore, the requisite knowledge or equivalent skills to perform the above in a safe and competent manner. Chronic interventional pain management constitutes the practice of medicine. The practice of chronic interventional pain medicine has been established as a separate and distinguished subspecialty of medicine in medical schools and in medical residencies and fellowships throughout the United States for decades. Established academic medical centers have pain medicine training programs within numerous medical specialties, and these training programs are recognized for eligibility for board certification and are recognized by the American Medical Association. Chronic interventional pain medicine training involves intensive medical training and education in academic and other medical centers by physicians who are themselves certified as physician pain medicine specialists.6 The duration of pain management training exceeds by at least one year the intensive medical residency period, adding one to two years to the duration of supervised medical interventions and treatments involving full-time patient care and responsibility as well as participation in research. Upon completion of a pain management residency, pain physicians are certified by the American Board of Interventional Pain Physicians (ABIPP). This board is recognized by the American Board of Medical Specialties (ABMS). The ABIPP certification exam exclusively tests the physician’s knowledge regarding pain assessment (5%), diagnostic testing (5%), pain syndromes 2 Spine Diagnostics Center of baton Rouge, Inc. v. Louisiana State Board of Nursing, 2008 WL 5351729, p. 14 (La.App. 1 Cir.) 3 Timothy Wayne McDuell v. Health Care Indemnity, Inc., 2001-0057, Medical Review Panel Proceeding, State of Louisiana. 4 Id. 5 Id. 6 ACGME Program Requirements for Fellowship Education in Pain Medicine. July 1, 2007. (15%), interventional techniques (15%), and other issues related to the practice of pain management.7 CRNAs do not possess the requisite education or training to practice medicine and, particularly, to perform chronic interventional pain management. Lack of training. Nurse anesthetists are required to have a bachelor’s degree which earns them an RN designation. They then undergo CRNA training which consists of 18-24 months of didactic and clinical training in administration of anesthetics. By way of example, CRNAs only receive a total of six to seven years of total education compared to a physician practicing chronic interventional pain management who is required to have a minimum education of twelve years, and several have up to sixteen years of documented education. CRNAs cannot document any formal education in performing chronic interventional pain management.8 In fact, the College of Accreditation’s (COA) current standards, last revised in January 2006, do not require nurse anesthetist programs to provide any clinical case experience in pain management (acute or chronic).9 Additionally, the COA does not list pain management in the description of “full scope of practice” for a CRNA.10 This acknowledgment by the national accreditation body that the medical specialty of chronic interventional pain management is beyond the skills of a CRNA further supports the separation between nursing and medicine. Since CRNAs cannot show any formal didactic or clinical training, many justify their competency to practice medicine by attending a weekend seminar. In a 2008 American Academy of Pain Management newsletter, it was reported that the American Association of Nurse Anesthetists was pursuing continuing education shortcuts to expertise in interventional painmanagement techniques. Through the Institute for Post Graduate Education, AANA is offering a 3-day Interventional Pain Management Cadaver Model Lab course for CRNAs. The course’s learning objectives include epidural steroid injections, discography, facet injections, coding, and cervical, thoracic, and lumbar radiofrequency lesioning. Although a 3-day comprehensive course in interventional pain management may not seem adequate for providing comprehensive knowledge in the discipline, it is the amount of training that most CRNAs receive in the practice of pain management. The prevailing argument is that doing epidural and selective nerve blocks for acute pain in the operation room will naturally extend to performing interventional procedures for chronic pain.11 7 Web. ABIPP Information Bulletin for Certification as Fellow for Interventional Pain Practice. http://www.abipp.org/forms/diplomate/default.aspx. Retrieved December 3, 2008. 8 Web. University of Iowa College of Nursing Anesthesia Nursing Course Sequence, (www.uiowa.edu). Retrieved November 24, 2008. 9 COA, Standards for Accreditation of Nurse Anesthesia Education Programs, 2004 edition, revised January 2006. p. 6-7. 10 Id. Glossary, p. 25. Note that this definition is attributed to “Scope and practice for nurse anesthesia practice,” available from the AANA. 11 Web. Francis, Michael. LSBN to Allow CRNAs to Practice Pain Management Procedures. Pain Medicine Network. Winter, 2008. 4. www.painmed.org/pdf/2008winter_newsletter.pdf. Lack of certification. Unlike physicians, the only certification a CRNA can receive in this area is from the American Academy of Pain Management (AAPM). In order to sit for the 100 question AAPM certification exam, one must only possess a bachelor’s degree in a health care related field.12 In addition, the exam rarely contains a single question regarding interventional pain management. This certification process may better inform a CRNA regarding patient pain but obviously is not designed to elevate a CRNA to the position of a physician pain specialist. Rural Access The Board reviewed state maps demonstrating the location and availability of pain management specialists throughout Iowa and along its bordering states. The maps show that at any given location within Iowa a patient’s access to chronic interventional pain management treatment is never more than 120 miles away. Chronic pain by its own terms (nature) does not require emergency treatment; rather, it has time to be treated. The availability of such treatment at the hands of trained specialists is more than sufficient to meet our rural citizen’s needs, while at the same time removes the risk of patients receiving such treatment form unqualified practitioners. Conclusion The Board concludes that the practice of chronic interventional pain management, including the use of fluoroscopy, is the practice of medicine and is not within the scope of practice of other health care professionals, including CRNAs. Physicians and osteopathic physicians are trained to diagnose and treat pain using a myriad of diagnostic techniques and a wide variety of treatment modalities. Advanced specialty training in chronic interventional pain management allows for sufficient education in pain, pain management and related areas, e.g., radiology, that supports the proper performance of chronic interventional pain management. Other health care professions, including CRNAs, lack the breadth or depth of education and expertise that physicians and osteopathic physicians possess in chronic interventional pain management. For this reason the Board finds that specialty trained physicians and osteopathic physicians credentialed, and actively engaged in, chronic interventional pain management are the most prepared to offer safe chronic interventional pain management. The Board recognizes that other health care professionals, including CRNAs, have a great deal to offer in the treatment of pain and the Board encourages physicians to work cooperatively with these other health care professionals. However, due to the inherent risks involved in chronic interventional pain management and the limited education and training possessed by other health professionals, including CRNAs, the Board finds that other professionals performing chronic interventional pain management procedures should do so only under the supervision of a physician or osteopathic physician who is actively engaged in the practice. Physicians and osteopathic physicians considering such supervision should have an appropriate understanding of the other health care professional’s training and experience in the proposed procedures. 12 Web. American Academy of Pain Management Credentialing Brochure, revised 01/31/08. www.aapm.com. Retrieved July, 2008. Minutes of the Iowa Society of Anesthesiologists: Annual Meeting Des Moines, IA 04/04/2009 Dr. Allaire convened the meeting at 2:45PM following the Annual Educational meeting. Minutes were approved from the 2008 meeting, moved by Drs. John Dooley and Steve Stefani. PRESIDENT’S REPORT Dr. Allaire discussed the state of the Society’s progress over the past two years in increasing advocacy and attention from legislators and government officials. The advocacy was born of direct challenges to anesthesiologists’ reimbursement. He reviewed the activities of the ISA PAC (see attached) and re-emphasized the need for support of the PAC. Dr. Allaire reviewed the concerns regarding patient safety that have been engendered by the attempt of non-physician practitioners to practice pain medicine. Through active work by Dr. Rosenquist at the University of Iowa and the officers of the ISA at the Iowa Board of Medicine, that Board has created a statement supporting the practice of pain medicine as solely the purview of physicians. Should that statement be finally approved, it will be of help in any further attempts of other practitioners to obtain ability to practice pain management via legislative or judicial means. However, it is possible that this may go forward to a legal challenge, with potential financial impact on the Society. Dr. Allaire alluded to the improved professional management of the Society with additional services including an invigorated web presence. He discussed the decision to retain a new lobbying firm, Policy Works, which the leadership anticipates will be of value in the Society’s advocacy in the wake of changes in legislative leadership. Dr. Allaire asked all to consider the cost of this advocacy and the possible need for dues increase. ELECTIONS Dr. Moyer nominated Dr. Tewfik for Secretary-Treasurer and Dr. Merrill seconded nomination. Dr. Tewfik was elected by acclaim. Dr. Cassady will be moving on to President as the inherent termination of his President-elect. Nominations for President Elect: Dr. Becker nominated and Dr. Cassady seconded the nomination of Dr. Merrill. No other nominations were made and Dr. Merrill was elected by acclaim. Iowa Medical Society Annual Meeting is in two weeks and ISA is eligible for 9 delegates: members willing to take on that role were Drs. Tewfik, Lederhaus, Merrill and Sundet. Dr. Douglas Merrill presented the Secretary-Treasurer’s report (attached) and commented on the increasing deficits, all of which are due to the above-mentioned advocacy. Dr. Merrill mentioned that the current economic and health-care reform status would likely require further advocacy. 1 ADVOCACY REPORT Mr. John Cacciatore of Policy Works gave a brief discussion of the legislative landscape in Iowa and the current state of Medicaid in Iowa. The Federal stimulus package should be of help, as Iowa Medicaid administrators were suggesting a 4% drop in payments if no stimulus was forthcoming. Revenues for the State as a whole are expected to be significantly lower than previous years; so that the stimulus package was appropriated in the Governor’s budget to maintain Medicaid at ‘status quo’ and that has been re-affirmed as a goal by legislative leaders. In regard to the general budget, the State departments are seeing budgets cut between 7 and 12% currently recommended in the Governor’s budget. Other legislative issues were discussed. BY-LAWS By-Laws changes – these were approved by acclamation: 1. To allow membership to medical students. This was passed by acclamation. 2. Edits of the By Laws were made to bring them into concordance with actual events regarding the annual fall meeting. 3. The raise of dues by $100 per member per year. OLD BUSINESS A new policy on privacy was requested at the last annual meeting and was prepared (see attached) and reviewed by the House. It was accepted by acclamation. NEW BUSINESS ISA is entitled to appoint a member of the Carrier Advisory Committee; John Dooley expressed interest and was appointed by the Society president. Respectfully Submitted, Dr. Doug Merrill Secretary-Treasurer 2 Anesthesia Services for Gastrointestinal Endoscopic Procedures 4/24/09 9:25 AM Anesthesia Services for Gastrointestinal Endoscopic Procedures Medical Policy: 07.01.45 Original Effective Date: July 2009 Reviewed: Revised: This policy applies to all products unless specific contract limitations, exclusions or exceptions apply. Please refer to the member's coverage manual for benefit availability. Managed care guidelines related to referral authorization, and precertification of inpatient hospitalization, home health, home infusion and hospice services apply. Description: This policy is effective July, 2009 This medical policy addresses anesthesia services during gastrointestinal endoscopic procedures. Anesthesia services include all services associated with the administration and monitoring of analgesia/anesthesia to a patient in order to produce partial or complete loss of sensation. Examples of various methods of anesthesia include moderate sedation, monitored anesthesia care, regional anesthesia and general anesthesia. Policy: Moderate sedation may be considered medically necessary when administered to average-risk adult patients undergoing general, diagnostic, uncomplicated, therapeutic endoscopy and colonoscopy. Other types of anesthesia services including monitored anesthesia care and general anesthesia may be considered medically necessary during gastrointestinal endoscopic procedures when there is documentation by the operating physician and the anesthesiologist of any of the following circumstances: A history of or anticipated intolerance to standard sedatives (i.e., patient is on chronic narcotic or benzodiazepine therapy, or has a neuropsychiatric disorder) Increased risk of complications due to a severe co morbidity (American Society of Anesthesiologists [ASA] class III physical status or greater). See additional information below. Prolonged or therapeutic endoscopic procedure requiring deep sedation Pediatric age group (younger than 18 years) Pregnancy History of drug or alcohol abuse Uncooperative or acutely agitated patient (i.e., delirium, organic brain disease, senile dementia) Increased risk for airway obstruction due to anatomic variant including any of the following: History of previous problems with anesthesia or sedation History of stridor or sleep apnea Dysmorphic facial features Presence of oral abnormalities including but not limited to small oral opening (less than 3 cm in an adult), high arched palate, macroglossia, tonsillar hypertrophy, or non-visible uvula http://www.wellmark.com/e%5Fbusiness/provider/medical%5Fpolicies/policies/_Anesthesia_Services.htm Page 1 of 3 Anesthesia Services for Gastrointestinal Endoscopic Procedures 4/24/09 9:25 AM Neck abnormalities including but not limited to short neck, obesity involving the neck and facial structures, limited neck extension, decreased hyoid-mental distance (less than 3 cm in an adult), neck mass, cervical spine disease or trauma, tracheal deviation, or advanced rheumatoid arthritis Jaw abnormalities including but not limited to micrognathia, retrognathia, trismus, or significant malocclusion. The routine assistance of an anesthesiologist or a certified registered nurse anesthetist (CRNA) for average-risk adult patients undergoing standard upper and/or lower gastrointestinal endoscopic procedures is considered not medically necessary. Additional Information: American Society of Anesthesiology Physical Status Classification: Class I: Patient has no organic, physiologic, biochemical, or psychiatric disturbances. The pathologic process for which operation is to be performed is localized and does not entail systemic disturbance. Class II: Mild or moderate systemic disturbance caused either by the condition to be treated surgically or by other pathophysiologic processes Class III: Severe, systemic disturbance or disease from whatever cause, even though it may not be possible to define the degree of disability with finality. Class IV: Severe systemic disorders that are already life threatening, not always correctable by operation. Class V: The moribund patient who has little chance of survival but is submitted to operation in desperation. Top Procedure Codes and Billing Guidelines: To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9-CM diagnostic codes. 00740 Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum 00810 Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum Top Selected References: Standards of Practice Committee, Lichtenstein DR, Jagganath S, Baron TH et al. Sedation and anesthesia in GI endoscopy. Gastrointest Endosc. 2008 August;68(2):205-16. Cohen LB, Delegge MH, Aisenberg J et al. AGA Institute Review of Endoscopic Sedation. http://www.wellmark.com/e%5Fbusiness/provider/medical%5Fpolicies/policies/_Anesthesia_Services.htm Page 2 of 3 Anesthesia Services for Gastrointestinal Endoscopic Procedures 4/24/09 9:25 AM Gastroenterology2007 August;133(2):675-701. American Society of Anesthesiologists Task Force on Sedation and Analgesia by NonAnesthesiologists. Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists. Anesthesiology. 2002; 96(4):1004-1017. Top New information or technology that would be relevant for Wellmark to consider when this policy is next reviewed may be submitted to: Wellmark Blue Cross and Blue Shield Medical Policy Analyst Station 304 636 Grand Ave Des Moines, Iowa 50309 *Current Procedural Terminology © 2009 American Medical Association. All Rights Reserved. Wellmark medical policies address the complex issue of technology assessment of new and emerging treatments, devices, drugs, etc. They are developed to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. Wellmark medical policies contain only a partial, general description of plan or program benefits and do not constitute a contract. Wellmark does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Wellmark or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. Our medical policies may be updated and therefore are subject to change without notice. http://www.wellmark.com/e%5Fbusiness/provider/medical%5Fpolicies/policies/_Anesthesia_Services.htm Page 3 of 3 ISA PAC 2009 Contributors Thanks for your contribution. Remember that you can make ISA PAC contributions online at the ISA website – www.iasocanes.org. Janet Acarregui MD Richard Aerts MD Patrick Allaire MD Michael Almasi DO Jeffrey Anderson MD James Becker MD Robert Beckman MD Christine Botkin MD Brian Bowshier M.D. Johnny Brian Jr. MD Jeffrey Buffo MD David Burkamper MD Christine Carstensen MD Joseph Cassady Jr. MD Meredith Crenshaw MD Kent Croskey DO David Crumley MD Louis DeWild MD Judith Dillman MD John Dooley MD Carrie Dykstra MD Robert Fears MD Ivan Fomitchev MD Courtney Hancock MD Tork Harman MD Maurice Hart MD David Haupt MD John Herring MD Bradley Hindman MD John Jabour MD Jamie Johnson MD Susan Karr-Peterson DO Robert Kitterman III MD Mark Kline MD George Lederhaas MD Jessica Leinen MD David Lind MD Nancy Lorenzini MD Stephen Maze MD Paula McFadden MD Douglas Merrill MD John Moyers MD Scott Murtha MD Trevor Ponte DO Robert Rossi, MD Julie Saddler MD Douglas Sedlacek MD Gary Shanks MD John Skoumal MD David Stein MD Hans Steine MD Lois Stoltze MD Christopher Teggatz MD Sherif Tewfik MD Gail Vandewalker MD Jason Walker MD Christopher Walsh MD Timothy Walsh MD