A “perfect storm” refers to a meteorological condition aggravated by a rare combination of circumstances. The most familiar reference is the 2000 movie “The Perfect Storm.” It is the story of the Andrea Gail, a small fishing vessel that was caught off the coast of New England in 1991 in a convergence of three major storms. There were no survivors.

The perfect storm has become a metaphor to describe when things go very wrong – when events spin wildly out of control.

This appears to be the case for anesthesiology payment. For many years, our collective focus has been on the “Medicare 33% problem.” Indeed, the inadequacy of Medicare payment has been a defining issue since the Resource-based Relative Value Scale (RBRVS) system was established in 1992 (ASA Monitor 2021;85:7-8). Despite ASA's success in gaining anesthesia-specific conversion factor increases of 16% in 1995, 1.6% in 2000, and...

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