CANS President
Cause and Effect
As I enter my second month as President of the California Association of Neurological Surgeons, I want to reaffirm my commitment to reaching every neurosurgeon in our state and inviting them to join CANS. My goal is for our membership to remain strong and for our conferences to serve as vital gatherings for education and community-building. Rest assured that our officers, Board of Directors, and consultants are continuously striving to create tangible value for every member—an especially important endeavor given the current economic challenges and inflationary pressures.
Through our work with the Council of State Neurosurgical Societies (CSNS), the California Medical Association (CMA), and our close collaboration with the Washington Committee, CANS actively promotes neurosurgeons’ interests on regional and national platforms. We also provide affordable CME opportunities and are committed to maintaining a family-friendly environment, reflected in our consideration of conference sites and activities that accommodate spouses and children.
I am pleased to highlight a new collaboration between CANS and the Congress of Neurological Surgeons (CNS). The CNS has extended a special membership promotion to CANS members who have not yet joined their organization. If you become a CNS member by April 11, 2025, you will receive two years of membership (2025 and 2026) for the cost of just one year—a savings of $1,030. Additional benefits include discounted access to valuable educational resources and the CNS+ App, as well as a sizeable reduction in registration fees for the 2025 CNS Annual Meeting in Los Angeles, which amounts to $1,241 in savings. To take advantage of this offer, simply email membership@cns.org with the subject line “CANS 2025,” and the CNS Member Services team will guide you through the process. I hope many of you will embrace this opportunity and help reinforce California’s significance as a host state for future CNS events.
Finally, this presidency has opened new horizons for me, offering the privilege of working more closely with our Executive Committee, consultants, and the various CANS committees. I have been truly inspired by the willingness of so many colleagues to volunteer their time and expertise for our collective success, and I am humbled by their genuine altruism. My heartfelt thanks go out to each of you. I look forward to our continued collaboration in serving the needs of California’s neurosurgeons—and the patients who depend on us.
Best regards,
Samer Ghostine, MSc, MD
President, California Association of Neurological Surgeons
Citations:
1. Council of State Neurosurgical Societies (CSNS).
2. California Medical Association (CMA).
3. Washington Committee for Neurosurgery.
4. Congress of Neurological Surgeons (CNS).
Medicaid cuts are again in the news, with Republicans proposing over $800 billion in savings over the next decade. It is important to clarify that these are not cuts to existing services but rather a reduction in the program’s projected growth. Pragmatic policy changes can achieve these savings without compromising care for our most vulnerable patients. In fact, many cost-saving measures would make Medicaid more efficient, ensuring funds are better targeted for patient care. A key policy objective should be to reduce Medicaid enrollment responsibly, as private insurance offers better access and outcomes for patients.
Medicaid has suffered from significant inefficiencies in eligibility oversight, leading to billions of dollars in improper payments. Many enrollees do not even realize they are covered, and states, along with Medicaid Managed Care Organizations, receive payments for individuals who are not utilizing services, some of whom already have private insurance. Addressing this issue alone could result in substantial savings. Introducing work requirements for able-bodied adults could further reduce Medicaid dependency. These policies would incentivize states and managed care organizations to develop employment assistance programs, improving both financial stability and health outcomes for beneficiaries. Research consistently shows that individuals engaged in the workforce experience better mental and physical health compared to those who are not. Work requirements can done in a compassionate manner, allowing exemptions for school, job training, caregiving of a sick family member, and medical reasons.
Medicaid was designed to support low-income individuals and the disabled, yet loopholes allow people with substantial assets but no active income to qualify. Reinstating asset tests would ensure that Medicaid prioritizes individuals who lack the means for private coverage. The purpose of Medicaid isn’t to preserve intergenerational wealth for the elderly to pass on to their children. Additionally, ensuring that coverage is reserved for American citizens would yield further cost savings.
For individuals near the Medicaid income threshold, a graded transition to private insurance is preferable to an abrupt loss of coverage. Under the current system, Medicaid enrollees face a sharp cutoff. Earning slightly more can make them ineligible, leaving them uninsured. Instead, Congress should encourage a graduated subsidy model, where individuals receive partial subsidies to purchase private insurance as they approach the Medicaid income limit. As their income rises, the subsidies decrease gradually, ensuring they maintain coverage. If income decreases, subsidies adjust accordingly, preventing gaps in care. Arkansas has successfully implemented a similar premium assistance program, which uses Medicaid funds to help beneficiaries buy private insurance. Expanding this approach nationally would allow Medicaid to function as a bridge to private coverage rather than a permanent solution.
States must also ensure they claim the Medicaid Drug Rebate for pharmaceuticals, capturing savings that are currently lost. Additionally, hospitals have exploited the 340B program, profiting from drug discounts intended for low-income patients. Instead of allowing hospitals to retain these profits, state Medicaid agencies should ensure that drug rebates benefit Medicaid directly, reducing costs while maintaining access to essential medications.
State Directed Payments allow states to allocate funds to critical areas without reducing beneficiary access. These payments give states the flexibility to support healthcare access without resorting to broad rate cuts or benefit reductions. Local control ensures that Medicaid funding is allocated efficiently, preserving care quality while improving fiscal sustainability. By improving efficiency and access, the downstream effects will save money.
Lastly, as with Medicare, Medicaid should drop its ridiculous quality metrics. Extensive data shows that quality metrics add to expense without actually improving quality of care. Federal mandates to Medicaid require over 80 total metrics. As if providing healthcare isn’t difficult enough, Medicaid is required to track and intervene on social needs as well, even though there are separate federal programs to cover housing, food, education and transportation. There are numerous metrics required for equity goals as well. While laudable, there is little evidence these do anything besides driving up cost.
Rather than serving as the default insurance option for a growing share of Americans, Medicaid should return to its original mission as a safety net for those who truly need it. Policies that reduce dependency while ensuring proper coverage transitions will strengthen Medicaid, preserve access for vulnerable populations, and make the program financially sustainable. Instead of measuring success by enrollment numbers, we should focus on how many individuals successfully transition to better coverage. A responsible reduction in Medicaid enrollment is not a failure. It is the hallmark of a well-functioning, efficient, and targeted safety net program that serves those in need while encouraging upward mobility for those who can move beyond government assistance.
“Without reflection, we go blindly on our way, creating more unintended consequences, and failing to achieve anything useful.”
-Margaret J. Wheatley
Several important things happen when things change or need to change. A new perspective is obtained, a new boss or associate comes in with new ideas, or some sort of secondary gain to change arrives. Changes in one’s own practice can have actions, both desirable and bad – seen and unforeseen. So too, we are seeing changes coming to our healthcare system and we should look carefully upon how to be better students of cause and effect, as well as the downstream effects of potentially trying to get rid of termites by burning down the house.
In the first instance, we see a surgeon change his or her habits, techniques, or approaches to their practice. This is very commonly seen after one of our academic meetings. We interface, get updates on the latest notions in our specialty, and sometimes abandoned things that we thought were good, but it turns out were not so great. Colleagues and surgeons in our specialty may comment or have an aside conversation where we can ask questions of one another about how they handle certain situations or if they’re still doing something that really hasn’t helped. We’re always looking for that game changer, and sometimes we find them, but for the most part, we are just barking up the same tree. These meetings can sometimes have negative consequences where we enter ourselves further into maladaptive behaviors or techniques. It’s important to keep going, however in order to stay current, as well as to have your practice and approach to patient care get better. Once you get past, of course, the chorus of “I’ve never seen that before”” or” that’s never happened to me”. These are all of course hyperbole and you can see and feel that rise the longer the meeting goes lasts. Herein lies the main reason I’ve stayed for shorter and shorter periods at the academic meetings. But I and we need to go.
In any case, sometimes the need for change is like a fence. That fence might be keeping you back. Or it might have some other purpose – like holding something back other than you. Imagine you are riding a horse on a large, sprawling ranch in say, Northern California, close to Yosemite. The property on the other side of the fence is unclaimed. So, you decide to take that fence down, because you want what is on the other side, damn the consequences.
Change or progress can come from new people on the other side of the fence. For instance, having a new colleague or associate can sometimes bring fresh perspectives. I’ve seen the number of deformity surgery skyrocket in the last eight years or so. I’ve also noticed in the community a quadrupling of deformity surgeries. On occasion, I see these patients in the hospital, I’ve been fairly disappointed one such case an academic surgeon in the community did a four-level lumbar fusion. Unfortunately, since the patient’s main problem was leg pain, the main nerve root that was compromised was at the bottom of the fusion. Meaning, the main driver of pain was not addressed. The films looked good though. Cynicism aside, I feel that having a new colleague does bring a different way of thinking about things. Also, it does add I think overall positive peer pressure for us all to look at problems slightly differently.
I don’t bill myself as a deformity surgeon, but I have done them. But I think it’s important to keep perspective that while we may venture into new techniques or ways of solving problems, that we rely on our own good judgment and just not try to be like everybody else, and know our own limits. Extending surgical capabilities is wonderful and exciting, possibly bringing new revenue streams. However, there is a road to hell and it’s paved with good intentions.
In the last circumstance, it’s a fairly dark and often not talked about reason for change. We are all aware of industry relationships, and the necessity to keeping our practices going and our academic meetings funded, but I think we can all say that we relate to a circumstance with a surgeon started doing a new technique because here she was getting honorarium or some sort of director ship or consulting from it. These are the worst kind of changemakers. And I think it’s important that we recognize them and speak to each other on this that not every spine problem needs the newest metal doodad and further, that these industry relationships are disclosed upfront to the patients.
In a recent era of change for the sake of change with the new administration coming in, we have seen some unintended consequences of changing the way things are done.
Anyone who has been involved in advocacy, knows that there is a market amount of waste and fraud in healthcare. And no matter how you feel about the administration, they are right to want to seek to save money.
What I have seen from talking to colleagues in the medical research space as well as those who are seeking grants and funding there’s been major disruption, both in funds and research applications. The impetus to save money (and maybe pass it along to Americans, or potentially fund a large tax break to wealthy comrades) can run you straight up into a fence of sorts: Chesterton’s fence.
A philosophical concept of the fence blocking “change” was discussed by G.K Chesterton (1874-1936). He speaks on it in his essay Heretics (1905):
“Suppose that a great commotion arises in the street about something, let us say a lamp-post, which many influential persons desire to pull down. A grey-clad monk, who is the spirit of the Middle Ages, is approached upon the matter, and begins to say, … ‘Let us first of all consider, my brethren, the value of Light. If Light be in itself good—. At this point he is somewhat excusably knocked down. All the people make a rush for the lamp-post, the lamp-post is down in ten minutes, and they go about congratulating each other on their un-mediaeval practicality. But as things go on they do not work out so easily. Some people have pulled the lamp-post down because they wanted the electric light; some because they wanted old iron; some because they wanted darkness, because their deeds were evil. Some thought it not enough of a lamp-post, some too much; some acted because they wanted to smash municipal machinery; some because they wanted to smash something. And there is war in the night, no man knowing whom he strikes. So, gradually and inevitably, to-day, to-morrow, or the next day, there comes back the conviction that the monk was right after all, and that all depends on what is the philosophy of Light. Only what we might have discussed under the gas-lamp, we now must discuss in the dark.”
(this is a free audiobook version for the interested: https://www.youtube.com/watch?v=l9CFkqm_I3A)
Here, Chesterton basically says, the fence you want to knock down, the system you want to change or even eviscerate was in place for a reason. And the second-order thinking is considering what taking that fence down will do. An analogy in spine surgery is the fusion of a single level. We have to consider the down-stream, global effects. The specter of adjacent level disease, and the longitudinal health of the patient and their spine.
So too, when you change things in your practice – from firing/hiring people, to using a new device or technique, to how you code your cases has downstream effects. On a macro level – hiring or firing tens of thousands of people when not really understanding who they are and what they do, only having to hire them back days later has consequences. The difference is when you are managing your practice, you are accountable to yourself and you are the agent of your own change: change comes from within.
For our healthcare system – there is graft on all levels – hospitals, insurers, administrators, and even doctors. It needs changing. But the difference is, the change in such a system is throwing a very heavy stone into a small pond. The ripples emanating outwards can become virtual tsunamis at the edges. Gathering knowledge before change is initiated by a motivated, and preferably not monetarily driven, individual or group. That group of people must be visible and accountable to those being affected by the change. Maybe not in so much as being elected to the positions, but having open discussions in the affected departments to gather information and to anticipate unintended and sometimes dangerous end-results from capricious action. But by all means – change it – but do it in a smart, fair, and visible to the outside way. An ombudsman’s office should be set up for employees and those affected by these changes in a way to fairly adjudicate mistakes (that just in the last 6 weeks there have been numerous), alert the auditors to downstream effects, and act as guardrails from monetary influence and self-dealing. One would think if the intents of such auditors were pure, there should be no problem dealing with questions.
Change, being a necessary thing to be more efficient, safe, and efficacious has to come. But we have to be accountable for the change and understand how the integrated parts are affected and of course the negative outcomes of when we pull down that fence that was out there for some reason on our ranch, only to find the wolves at our front door in short order.
Chen LJ. Health Policy Challenges for 2025 and Beyond. JAMA Health Forum. 2025;6(1):e250184. doi:10.1001/jamahealthforum.2025.0184
Neurosurgeons and physicians are and should be keenly aware of their individual systems as well as the US healthcare system as a whole. Despite all of us striving for high quality care and to improve access, there have been noted issues regarding access and cost that affects quality of care. There have been numerous efforts to reform the system including the Affordable Care Act, but there are certain important policy deadlines that Dr. Chen has appropriately pointed out that may significantly affect the way we all practice. At the end of 2025, ACA subsidies that many patients utilize to enroll in qualified health plans through exchanges are scheduled to end. Furthermore, with a new administration there are many areas that may be affected including Medicare, and tax Code related provisions.
Dr. Chen points out that as it stands, health-related tax expenditures are estimated to increase by 15% (more than 51 billion). This is a result of expirations of provisions within the Tax Cuts and Jobs Act (TCJA) which directly affect employer-sponsored insurance tax exclusions. Dr Chen suggests that Lawmakers may not let the individual cuts from the TCJA expire however this is certainly not a guarantee—this could directly affect our patients. Furthermore, it is suggested that policies to reduce consumer costs could be investigated such as evaluating rules for health savings accounts, deductions for out of pocket expenses or even using pre-tax dollars for primary care. Due to these expirations, it is certainly a unique and important time for neurosurgeons to lobby their legislators to discuss ways to ensure our patients can continue to have access to quality care or improve access—perhaps suggesting provisions to provide tax incentive for costs related to seeing specialists or even for imaging which can sometimes be difficult to get covered. Perhaps this will allow for improved utilization and allow for decreased burden for patients to seek neurosurgical care that need it.
The ACA subsidies are also noted to be expiring. These were initially expanded in 2021 during the pandemic to help support patient’s access to government support for insurance through exchanges to 400% of the federal poverty line. These are set to expire at the end of 2025 and it’s estimated that 5.6 million people will no longer be eligible to be subsidized. This is a huge hit to the population and certainly will affect coverage. This will almost certainly affect all of us as neurosurgeons who may have patients be unable to afford their care as they are undergoing a work-up or may cause more patients to be admitted to the hospital who do not already have insurance. This could create a huge payment issue that may affect reimbursement and hospitals. Evaluating which portions of these subsidies can be extended if not all of them should be evaluated or to propose additional ways to ensure that this loss of funding does not occur especially in a time when federal spending is increasingly under fire.
Other issues discussed in the article that are of physician payments and prescription drug costs. The IRA of 2022 capped rates of inflation for certain drugs and allowed for negotiation of drug costs for Medicare and Medicaid. There are pros and cons to this as the price reduction based on initial changes (found in September 2022) were only reduced by 22% which was less than expected, concerns additionally included that innovation by industry may be reduced if they do not have the financial incentives to develop new drugs. However ensuring access to quality drugs that patient’s need and may not be able to afford is critically important as we have all seen when patient’s are non-compliant with medications leading to comorbidities that have directly affected their outcomes. Therefore these concerns need to be balanced with ensuring access for critical medications.
Finally, payments to physicians is an ongoing issue. The sustainable growth rate has been frequently discussed and was initially created in 1997 to contain costs with eventually scheduled cuts to payments. MACRA (Medicare Access and CHIP Reauthorization Act) replaced cuts to physician payments with annual increases, albeit small ones but these increases will expire in 2025 therefore without prompt intervention in 2026 payments are scheduled to have a sharp cut. MACRA also started the “Quality Payment Program” with Merit-Based Incentive Payment or Advanced Alternative Payment models, which evaluate quality metrics and different additional categories to establish payment. Ensuring that reforms take place to better align what we want as neurosurgeons is critical and it is important for all of us to discuss and lobby for changes this year to ensure that 1. These cuts are not as steep as planned and 2. Whatever new system is designed or extended best aligns with our needs in healthcare so we can focus on the patient.
In summary, there are critical expiring provisions that we need to be engaged in that will directly affect physician payments, medication costs to our patient, insurance cost and therefore access to our patients and tax subsidies to business and patients that may directly impact our ability to care for our patients. Further, it is increasingly important this year to be involved in advocacy efforts with a new administration with these changes afoot to ensure that we, as neurosurgeons, can engage with our congressmen and congresswomen to try to drive changes in critical areas.
Anthony DiGiorgio, DO
Dr. Brazdzionis provides a thorough summary of the key issues raised in this month’s article. Lanhee Chen is a highly respected policy analyst at Stanford, and it’s refreshing to see JAMA publish his insights. His policy recommendations emphasize pragmatic, real-world solutions to the challenges our patients face. Like mine, his policy preferences strongly favor patient autonomy and market-driven reforms.
For example, he highlights the benefits of health savings accounts and direct primary care—two mechanisms that enhance patient choice and financial control over healthcare decisions. Importantly, Chen acknowledges that targeted reforms can simultaneously reduce costs and expand coverage. A more efficient system is inherently more equitable.
Lastly, and perhaps most critically for physicians, he addresses the persistent issues with physician payments. The challenge lies in aligning cost containment with incentives for high-value care—a goal that policymakers and physicians alike agree on. However, as always, the details of implementation will determine whether these reforms succeed in practice.