NEWS AND ANNOUNCEMENTS

FOCUS ON THE EMPLOYEE RETIREMENT INCOME SECURITY ACT (ERISA) AND ORAL ANDMAXILLOFACIAL SURGERY

The Employee Retirement Income Security Act(ERISA) was enacted in 1974 to regulate the em­ployee benefit plans. ERISA, which is administeredfunds, and encourage the development of other em­ploye benefit plans. ERISA, which is administeredby the United States Department of Labor, governsemployee benefit plans and trusts established andadministered by an employer or employee organi­zation.

Since its enactment, courts have interpretedERISA as prohibiting states from subjecting em­ployee benefit plans to state insurance laws. Spe­cifically, this means that all self-funded or self-in­sured benefit plans are subject to federal ERISAregulations and not state laws. It is important tonote that ERISA's preemption of state insurancelaws.does not extend to policies purchased from aninsurance company or to employee benefit plansmaintained by outside insurance agencies. Essen­tially, any state law directly regulating an employeebenefit plan is preempted by ERISA, but laws reg­ulating insurance companies or insurance contractsare not preempted.

ERISA's broad preemption clause was includedin the act to prevent state laws from interfering withthe development of new employee benefit pro­grams. Unfortunately, judicial interpretation ofERISA has allowed these self-funded benefit plansto escape state insurance "freedom of choice"laws, contrary to the original statutory intent of theact.

Many states have enacted "freedom of choice"laws to protect the employee/patient's right to se­lect the licensed health-care practitioners of his orhcr choice. Under these laws, insurance companiesand other third-party payers must comply by reim­bursing the patient or practitioners chosen by thepatient to provide health care regardless of degree.

Another "freedom of choice" issue raised by theERISA preemption clause is related to reimburse­ment policies based on the discipline of the pro­vider as opposed to the nature of the services ren­dered. Discipline of provider regulations, whichprovide that insurance policies shall not discrimi­nate in reimbursement between physicians andother types of health practitioners acting within thescope of their license, are part of insurance codesin 43 states. These discipline of provider provisionshave been designed and -implemented to preventdiscrimination against legally qualified health-carepractitioners. Since 1972, the AAOMS has had thelegislative goal of encouraging state OMS societies,in conjunction with their state dental associations,to obtain the "discipline of provider versus natureof service" provision in their states' insurancecodes. The following states have yet to enact dis­ciplinc of provider provisions as part of their stateinsurance codes: Alaska, Delaware, Idaho, Iowa,North Dakota, Rhode Island, Vermont, and theDistrict of Columbia.

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It is the interpretation of ERISA's preemption ofthese state "freedom of choice" laws that iscausing concern among oral and maxillofacial sur­geons and other health-care practitioners. Someemployee benefit plans have claimed that theERISA preemption of these "freedom of choice"laws allows reimbursement for health benefits to belimited to only doctors of medicine and osteopathy.One benefit fund blatantly stated: "If a surgicalprocedure is performed by an MD, and the trust'sconsultant has determined that the claim is medicalin nature, benefits will be paid. If a surgical pro­cedure is performed by a DDS (even though qual­ificd), benefits are not paid."

The United States Department of Labor, in itsadministration of ERISA, has compounded theseproblems by indicating that the exclusion of a den­tist or an oral and maxillofacial surgeon from a trustplan's definition of "doctor" does 1101 violateERISA provisions. This is particularly discouragingin light of dentistry's success in acheiving Congres­sional recognition in Medicare of the discipline ofprovider provision. The AAOMS and the ADA lob-

.bied successfully for an overlap provision that al­lows Medicare reimbursement for surgical proce­dures performed by dentists if such procedures arewithin the scope of their license. In other words,the Medicare overlap provision allows for reim­bursement to either MDs or DDSs if both are li­censed to perform a given procedure.

The AAOMS is addressing federal legislation byworking to obtain a similar overlap provision forTitle XIX of the Medicaid Act. One major obstacleto this effort is that states have the option to pro­vide supplementary dental programs under Medi­caid and, therefore, enactment of the overlap at thefederal level for the Title XIX program was viewedas unnecessary. Consequently, the AAOI\IS isurging state OMS societies to work toward stateadoption of overlap provisions similar to the Medi­care provision. The following is an example of onesuch state provision, enacted into law in Louisianain September 1984:

Be it enacted by the Legislature of Louisiana:Prohibition of discrimination against dental careservices. The office of family security, Depart­ment of Health and Human Resources, shallmake available to-persons who are eligible forMedicaid benefits under Title XIX of the SocialSecurity Act inpatient hospital services, outpa­tient hospital services, prescribed drogs, and allother services incident to professional treatmentprovided by a licensed dentist when the treat­ment and service is otherwise authorized and in­cluded in the Louisiana state plan for medicaland dental assistance when provided or pre­scribed by a physician or any other licensedpractitioner of the healing arts, provided that thedental health care shall be within the scope ofdental professional practice as defined by R.S.37:751 et seq.

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The AAOMS is working in conjunction with theADA and other health-care practitioners to amendERISA. Efforts are being aimed at clarifyingERISA preemption with respect to state "freedomof choice" laws prohibiting discrimination in reim­bursement among health practitioners. Both theAAOMS and the ADA contend tht is was never theintent of ERISA to preempt state insurance laws.They further contend that alternative languagemust be introduced into the act to protect the em­ployee's right to receive health care from the prac­titioner of his or her choice and to prevent discrim­ination against legaUy qualified health-care practi­tioners.

Amending ERISA is easier said than done. Whileassociation representatives have received positive

THE COMMITTEE ON RESIDENCY EDUCATION ANDTRAINING SEEKS A FOUR-YEARTRAINING PROGRAM

For more than five years, the Committee on Res­idency Education and Training (CRET) has ad­dressed the pros and cons of changing the length oforal and maxillofacial surgery training programsfrom three to four years. Arguments for both-sidesof the issue have been strong and varied.

The process of changing residency program re­quirements is time consuming. It includes reviewand comments from all interested parties, the pro­gram directors, deans of dental schools, and chiefsof departments of dentistry; discussions and rec­ommendations by the AAOMS' Section on Edu­cation and CRET; approvai of the AAOMS Boardof Trustees; approval of the AAOMS House of Del­egates; transmittal to the Commission on DentalAccreditation of the American Dental Associationand action on the part of that commission; and, fi­nally, time for implementation of any changes bythe programs involved.

In 1982, CRET prepared a position paper on four­year programs for OMS training and submitted it tothe Board of Trustees in January 1983. The positionpaper discussed in some depth a cross-section ofopinions from leaders in OMS and chiefs of OMStraining programs. While opinions on a four-yeartraining program differed, almost all agreed that thescope of OMS has changed significantly over thepast 15 years, since the 1969 adoption of the three­year training program, and that these changes willcontinue in the foreseeable future. In the paper'sconcluding statements, Dr. W. Robert Hiatt, chair­man of CRET, submitted that: "There will mostlikely never be unanimity of opinion as to how theultrastructure of a program should be devised.However, the three-year program recommended 15years ago might as well have been recommended 30

responses from some congressional sponsors forthe proposed amendments, there is reluctance toopening the act for amendment at aU. ERISA in itspresent form was a hard-won battle in Congress dueto opposing pressures from' both labor and businessinterest groups, and there is a hesitancy on the partof Congress to redraw those battle lines.

Until such changes can be made, the AAOMSadvises its fellows and members to seek predeter­mination of benefits prior to performing any sur­gical procedure under a health plan governed byERISA regulations. The AAOMS Committee on

_Governmental Affairs encourages feUows andmembers to provide copies of instances of discrim­ination under health plans governed by ERISA reg­ulations to AAOMS headquarters.

years ago in light of the changes in oral and max­illofacial surgery in this short span of years. A re­quired four-year program is thusly recommended."

1982 also saw the formation of the Section onEducation. The section was formed to have a voicein the educational process and to make recommen­dations to CRET; two nonvoting members sit onthat committee.

In the spring of 1983, at the request of the Boardof Trustees and in conjunction with CRET and theSection on Education, a survey was conducted ofchiefs of three- and four-year training programs tobe used by CRET and the Section on Education inmaking a recommendation to the Board of Trustees.Based on the committee's discussions and the re­sults of the survey, CRET recommended that theBoard ofTrustees approve the concept of increasingthe length of training programs to four years, notingthat:

The AAOMS bears a public responsibility formaintaining an appropriate standard of trainingfor the oral and maxillofacial surgeon; com­plexity of oral and maxillofacial surgery practicehas significantly increased and additionaltraining in oral and maxillofacial surgery shouldbe provided oral and maxillofacial surgery resi­dents; the current Essentials of All AdvancedEducational Program ill Oral and MaxillofacialSurgery mandates no less than 24 months of the36 months be devoted to clinical oral and max­illofacial surgery experience; the comprehensivemedical and surgical training of an oral and max­illofacial surgeon requires meaningful rotationsin anesthesiology, medicine, and surgery as wellas research; and a potential total of 72 (62.1%)of the 116accredited residency programs in oraland maxillofacial surgery are planning to offer aminimum of four years training.

Resolution 27, as submitted by CRET to theboard for consideration and transmittal to theHouse of Delegates, read:

RESOLVED, that the AAOMS officially under­take the appropriate measures to petition theAmericanDental Association to increase the ac­creditation requirement from 36 to 48months fororal and maxillofacial surgery trainingprograms,effectiveJuly I, 1986.

Upon the recommendation of the board , the Houseof Delegates adopted the resolution at the 1983 an­nual meeting.

Following the adoption of Resolution 27 by thehouse, the executive committee of the Section onEducation met to prepare a program for a specialmeeting of the section and CRET to consider andmake recommendations on the minimum require­ments for quality education in OMS with a viewtoward the house's recommendation to extend thelength of OMS training programs to four years. Thisspecial meeting took place in Boston in May 1984.

The next step will be a review of the May 1984section workshop papers by CRET, which meetsagain in March 1985. Recommendations fromCRET will be considered by the Board of Trustees ,which in turn is scheduled to make an official rec­ommendation, with background justification, to theCommission on Dental Accreditation of the ADAby May 1985. The commission then could begin itsown review process, initially addressing the changeat its May 1985 meeting. Hearings will have to beconducted by the commission on the change duringthe 1985-1986 year, with time allowances made forcomments on the change by institutions, includingchiefs and faculty of OMS training programs. A de­cision on the proposed change is not expected fromthe commission before its May 1986 meeting. As­suming the commission rules in favor of the pro­posed change, a schedule for implementation willthen be devised and disseminated to OMS trainingprograms for action. The earliest projected date forcompliance to the proposed switch to a four-yeartraining program would be in 1988.

CHANGE IN QUALIFICATIONS FORLIFE FELLOWSHIP

During the Association's 66th Annual Meeting inNew York, the House of Delegates amended thebylaws to expand the qualifications for life status.The bylaw has been broadened to include those fel­lows or members who have been paying dues for35 years but who have not yet reached 65 years ofage .

Chapter l. Membership, Section 20. Qualifica­tions, Item C. Life Fellow or Member, now reads:.. A fellow, member or affiliate member may applyfor the status of life fellowship or membership uponcompletion of thirty dues-paying years and reaching

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the age of 65 or upon completion of thirty-five dues­paying years ..."

Applications for life status can be obtained bycontacting: AAOMS Headquarters, MembershipSecretary, 211 East Chicago Avenue, Suite 930,Chicago, Illinois 60611 or by calling toll free 1-800­822-6637. Deadline for submission of applications isSeptember 1, 1985.

NAMES IN THE NEWS

Stephen R. Sewall

Appointed: Steven R. Sewall, of Waukesha, Wis­consin , as assistant professor of oral surgery at theMedical College of Wisconsin (MCW).Elected: As 1984-1985 officers of the Maryland So­ciety of Oral and Maxillofacial Surgeons: RichardJ. Sim eone of Potomac, Maryland-President;Howard R. Strauss of Cumberland, Maryland­President-elect; J. Thomas Soliday of Gaithers­burg, Maryland- Vice-president; and Frank J .Romeo of Baltimore, Maryland-Secretary-trea­surer.As new officers of the Western Society of Oral andMaxillofacial Surgeons during its 11 th AnnualMeeting last August: Walter /I. Fox of Eugene, Or­egon-President; Gerald G. Huffman of Oswego,Oregon-Vice-president; and Thomas G. Walsh ofCoeur D'Alene, Idaho-Secretary-treasurer.C. Ronald Spaulding of SI. Johnsbury, Vermont, aspresident of the medical staff at Northeastern Ver­mont Regional Hospital. Dr. Spaulding is also pres­ident of the Vermont Society of Oral and Maxillo­facial Surgeons.

Bill C. Terry

Honored: Bill C. Terry, Professor of Oral and Max­illofacial Surgery at the University of North Caro-

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Iina, awarded the third annual William F. HarriganAward for excellence in the specialty of oral andmaxillofacial surgery by the Bellevue Oral SurgeryAlumni Association. The award was presented toDr. Terry during the AAOMS Annual Meeting inNew York City.

Late Neil's con tinlied

CAN and its counterpart in the ASA or through a specialliaison group committee. This direct liaison is thought tobe necessary to inform the ASA of OMS education andtraining in anesthesia with the view of clarifying the ASAsposition and statements regarding the administration ofanesthesia by dentists and the training of oral and max­illofacial surgeons and dentists in anesthesia. This rec­ommendation has been forwarded to the Board ofTrustees for consideration.

The ASA House of Delegates, in October 1984, ad­dressed suggested revisions of the ASA statement on thetraining of dentists and oral surgeons. The proposedamendment to the statement suggested deleting the word"heavy" before IV sedation and adding the followingsentence: "Dentists and oral surgeons, when adminis­tering an anesthetic in the hospital setting and iniambu­latory freestanding surgical centers, should be under themedical direction of an anesthesiologist." The ASAhouse deferred the amended statement back to committeefor study, due in part to strong expressions of concernfrom ADA and AAOMS regarding potential misinterpre­tation of the proposed changes.

In another issue related to furthering the relationshipbetween the AAOMS and the ASA, the committee dis­cussed adopting requirements for advanced cardiac lifesupport certification for oral and maxillofacial surgeonsas they administer general anesthesia and deep sedationin outpatient facilities. The committee has recommendedthat the Board of Trustees take the necessary steps torequire AAOMS fellows and members to obtain the Ad­vanced Cardiac Life Support (ACLS) certificate by 1986and maintain its currency. To familiarize oral and maxil­lofacial surgeons with the ACLS course and certificationand to assist in arranging such programs at state and re­gional levels, CAN submitted a program on "An Intro­duction to Advanced Cardiac Life Support" for consid­eration by the Committee on Scientific Sessions for pre­sentation during the 1985 annual meeting.

The committee noted that the ADA Council on DentalEducation, in May 1984, endors~d the proposed revisionof Parts One and Three of the "Guidelines for Teachingthe Comprehensive Control of Pain and Anxiety in Den­tistry." CAN considered Part One on "Teaching of PainControl and Conscious Sedation" as acceptable but didnot agree with Part Three, which presents "Guidelinesfor the Teaching of Pain Control and Conscious Sedationin a Continuing Education Program." The committee be-

Robert A. Atterbury of Oak Park, Illinois, by theWest Suburban Hospital Medical Center at its 7thAnnual Reception for Staff Members for his "ded­icated, loyal and valued services." Dr. Atterbury isthe first oral and maxillofacial surgeon to receivesuch recognition from that institution.

Iieves that anything beyond the administration of nitrousoxide for conscious sedation cannot be taught in a con­tinuing education course. The committee developedcourse-length guidelines for teaching various methods ofpain and anxiety control and moved that the Board ofTrustees support these guidelines and officially recom­mend them to the ADA Council on Dental Educationbefore the March 15, 1985 deadline for comments. CANfurther recommended that the AAOMS defer any ap­proval of the ADA guidelines until the CAN's recommen­dations have been considered ana included in the guide­lines . In a related manner, the committee recommendedthat the AAOMS go on record with program directorsand others as being opposed to short anesthesia coursesthat are specifically designed to educate individualswithout credentials to be qualified to perform general an­esthesia and deep sedation.

In other business, the committee has 'recommended thecontinuation of an annual survey on morbidity and mor­tality using the same format for the 1985 survey as wasused in 1984. The committee further suggested that the1986 survey requesting anesthesia data for the year 1984­1985 be directed to individual fellows and members in­stead of state societies to obtain a more accurate re­sponse. The states then would be responsible only forrecord keeping of the office anesthesia evaluation pro­gram. The forms for maintaining records for the 1984­1985 year will be mailed to individual practitioners at thesame time as the survey is distributed to state societyofficials for this year.

The training of individuals who assist oral and maxil­lofacial surgeons in the administration of anesthetics haslong been an issue of interest to the ASA. Their statementindicates a belief that no one individual can simulta­neously perform a surgical procedure and administer theanesthetic. The committee proposed that the AAOMSbecome involved in educating anesthesia assistants. Tofacilitate this involvement, CAN recommended that theAAOMS Board of Trustees approach the Southern Cali­fornia Society of Oral and Maxillofacial Surgeons(SCSOMS) to discuss adopting its educational programfor anesthesia assistants. The SCSOMS, in 1972, per­mitted the AAOMS to use its office evaluation manual,which is now undergoing a second revision. Should theygrant permission to use their anesthesia assistant educa­tional program, the committee will request a secondmeeting to develop the details for such a program.