CANS President
Cause and Effect
As I step into the presidency of CANS, I find myself reflecting on the unpredictability of life. The past few years have been a testament to this, with unprecedented challenges—wildfires, political shifts, economic uncertainties, inflationary pressures, and evolving compensation models—placing immense strain on our profession, particularly here in California. And all of this follows the devastating impact of the COVID-19 pandemic.
Yet, just as we have weathered past storms, we will overcome these as well. Neurosurgeons are no strangers to adversity, and our collective resilience remains our greatest strength. Though we are a relatively small specialty, our representation at both the national and regional levels and our brand are strong. It is imperative that we continue advocating for our profession and our colleagues. A key priority during my tenure will be to reach out to the many California neurosurgeons who are not yet part of CANS and encourage them to join us in strengthening our voice. CANS stands as a unifying force, representing neurosurgeons across all practice settings and backgrounds.
My own journey has shaped my appreciation for the power of community. I grew up in Lebanon, a country torn by civil war, where instability and uncertainty were a constant. My family and I were forced to relocate repeatedly – changing homes, countries, schools, and at times, enduring painful separations. Coming to the United States was the greatest blessing of my life. Here, I was able to further my education, establish a career, build a stable family, and now, have the privilege of giving back and serving both my community and my profession. Achieving the “American Dream” was accessible through hard work, but throughout, it has been profoundly rewarding.
In times of past uncertainty, CANS has provided me with a sense of belonging and reinforced the value of resilience. I have cherished the opportunity to bring my family to many of our meetings, and as president, I look forward to fostering an even greater sense of community within our organization. Together, we will continue to stand strong, advocate for our specialty, and support one another through the challenges ahead.
I look forward to working alongside each of you in the year ahead,
Samer S. Ghostine, MD
President, California Association of Neurological Surgeons
Microsoft teams … never as smooth as Zoom in my experience. I always have to open it twice before it works.
It is the monthly Department of Surgery meeting, and I am already late. Because these meetings are always on my on-call/surgery day, I miss them frequently. Five-thirty in the evening is not a good time. Meeting or not, I usually stay late in the hospital on Tuesdays, eating dinner there and doing “paperwork,” even when there is nothing much else going on. I do not expect to be home for dinner tonight.
This Tuesday is different. I only had one elective surgery, and it has not been a super busy day in the ED … because the winds outside are so great? There is something on the TV about a fire in the Palisades, but that is the other side of town. For whatever reason, contrary to my usually practice, I decide to go home early and do the remote meeting from my living room. Is there a subliminal message that is being channeled through to me? Why am I there?
I am sitting, somewhat awkwardly and uncomfortably, in front of the laptop. The meeting, as usual, is painfully dull, and it is not easy to be attentive. But my level does perk up when the guy who is running the meeting, from his office up in Altadena, tells us quite suddenly that the has noticed that the hillside behind him has caught fire … he can see it through his window. Twenty minutes later he says that he must leave, pronto, and a colleague takes over the meeting.
Fast forward a couple of hours, as I venture outside. The wind is howling and the side of the mountain, about 3 miles away, is ablaze. No smoke yet, but the wind seems pointed in our direction.
I realize that I have little gas in my car, and think that I need to correct that situation, so I go out to get some. I avoid the hazards of a few downed trees and am surprised that it is easy to get gas not too far from my house. I expected long lines and tons of traffic from people fleeing the fires.
Back at home I put on all the sprinklers and hose everything else down as best I can. Still no smoke or embers, but it is getting a little scary. Cathy fills the bathtub with water, then we, stupidly, decide to go to sleep. The ED calls a few times, and I learn that there is a 17-year-old with a partial cauda equina injury, from an unstable L3 fracture (a tree fell on him), that I will have to operate on in the morning.
Fortunately, we had, also, loaded the cars up with old family photos, keepsakes, insurance and other papers and some clothes and toiletries, before we went to bed. We are good to go when we notice an evacuation order on the Watch Duty app on our phones, at 05:30. All we have to do is throw the dog in one of the cars and leave.
It is now late morning; I am in the OR fixing the kid’s spine. His pedicles are small. I am struggling a bit. We are all great abnegators. But putting the fires out of my mind, wondering on the fate of my house, is making full concentration difficult. I muddle through, and it turns out well. The smoke stench in the hospital is pretty bad, but the ultrafiltration in the OR makes it the one place where the stink is absent. Burning houses smell different from burning trees and logs.
That evening, reports suggest that our house is not going to burn. The winds are dying down. We are staying with friends in a non-evacuation area. Blessed, compare to many colleagues, we are back in our place after two nights.
Coincidentally, I had booked some time off work. We canceled a trip to Europe, as we were scheduled to leave the day after we evacuated and think better of it. But when things do not look too bad for us, we escape to Maui. It is good, but not great.
Survivors guilt, perhaps. Or just human empathy. The drive through Lahaina, which was leveled by a fire a year and a half ago, is surreal. The concierge lady where we are staying says she cannot not look at the TV stories on the LA fires. It is one thing losing your house and all your possessions, she tells me. But running for your life is another matter. Sounds like PTSD. Ninety-nine people died in that fire, many others barely escaping safely into the ocean.
Not so many deaths in the Eaton Canyon and Palisades fires, but the devastation is vast and is affecting everyone in the area, on one level or another.
In our jobs we see tragedy every day, but rarely on such a scale. Mother Nature can be very unkind.
Graphic of the month: A successful CANS meeting was capped by a celebration at the house of outgoing president, Ciara Harraher. CANS is stronger than ever heading into the presidency of Sam Ghostine!
Healthcare policy debates tend to be negative. For 2025, this newsletter will take on a more positive, forward-looking tone. To start, I propose outlining a promising path forward: physician-owned hospitals. Drawing inspiration from the success of physician-owned ambulatory surgery centers (ASCs), this model offers a blueprint for transforming entire hospital systems by returning control to frontline healthcare professionals.
The cornerstone of this vision is a governance structure that places physicians and nurses both on the board and as shareholders. This isn’t merely about financial stake – it’s about creating a system where those making daily patient care decisions also shape institutional policy. As hospital reimbursements continue to rise, this model enables healthcare professionals to access revenue streams previously closed to them, allowing us to reclaim autonomy and influence over healthcare delivery.
The current disparity in revenue distribution is striking: for a Medicare patient undergoing brain tumor surgery, the neurosurgeon’s professional fee is approximately $1,400 while the hospital typically collects $25,000-30,000. Similarly, for a hip fracture, the orthopedic surgeon’s fee is about $900 while the hospital takes in $17,000-20,000 for complex cases.
Beyond these facility fees, hospitals access numerous additional revenue streams that physicians cannot: substantial facility fees for imaging services (particularly relevant for neurosurgical care, where a single MRI can generate more facility revenue than the surgeon’s professional fee for a complex brain tumor), the 340B Drug Pricing Program which provides significant pharmaceutical discounts, Disproportionate Share Hospital (DSH) payments for serving low-income populations, graduate medical education funding, and various quality program incentive payments. These dramatic differences in reimbursement and revenue opportunities – with surgeons receiving only 3-5% of the total payments while being excluded from other major revenue sources – highlight the current misalignment of financial incentives in healthcare delivery.
By allowing physicians to be shareholders in a full-service hospital, these streams can be more equitably distributed. This alignment of incentives encourages efficiency, innovation, and improved patient care, as clinicians have a direct hand in deciding how best to deploy resources.
Every policy and operational decision within this model is designed to strengthen the direct connection between physician and patient. When those who deliver care also set policy, clinical outcomes and patient satisfaction naturally take precedence over bureaucratic convenience.
To achieve this, each service line is led by actively practicing physicians and nurses, ensuring decisions are guided by real-time clinical experience. Administrative staff, too, would regularly participate in patient care to stay grounded in the realities of bedside practice.
Engaged primary care physicians can better coordinate inpatient care, ensuring that patients consistently see the same doctor. This continuity enhances outcomes, reduces error rates, and fosters trust. It is a return to healthcare’s fundamental principle: fostering deep, ongoing relationships rather than transactional encounters.
Next-generation Electronic Medical Record (EMR) systems would further simplify documentation. Powered by artificial intelligence and large language models, these systems can reduce administrative burdens and eliminate the need for physicians to spend excessive time at a computer if they so choose. Meanwhile, on-site childcare and flexible staffing promote work-life balance, addressing a key driver of burnout.
Finally, physician ownership aligns incentives so that telehealth consultations among specialists become a collaborative, patient-centered enterprise rather than a new billing avenue. No more note bloat trying to capture every E&M code. When each stakeholder shares in revenue streams, there is less pressure to overbill or inflate costs, which ultimately benefits patients.
While all this sounds great, the bills must be paid. Transparent, easily searchable pricing for all services enables direct contracting and reduces dependence on healthcare middlemen. Imagine going to local employers and offering directly contracted rates for primary care, imaging, labs, and elective procedures. This transparency not only benefits patients but also streamlines operations and reduces administrative overhead. When combined with physician ownership, this creates a more efficient and cost-effective healthcare delivery system.
This isn’t merely theoretical – successful models already exist. Independent, physician-led organizations across the country are already directly contracting with employers, with Physician-Led Healthcare for America serving as a dedicated champion for this approach. Direct primary care practices and cash-pay surgical centers have consistently demonstrated the quality improvements and cost savings that come with physician ownership and direct contracting. These real-world examples provide tangible evidence that market-driven, physician-led healthcare delivery works. When combined with hospital ownership, this model promises an even more efficient and cost-effective healthcare delivery system.
The biggest hurdle to physician-owned hospitals is a provision in the Affordable Care Act that effectively bans new or expanded physician-owned facilities. However, political support is emerging to overturn this restriction, including a surprising but potentially powerful ally in the insurance lobby, which opposes further hospital consolidation.
Stark Law is another impediment. Initially designed to prevent self-referral abuses, it now often inhibits value-based, physician-led care. Exceptions exist—like the in-office ancillary services exception—but the law’s complexity has a chilling effect on many innovative ownership arrangements. Reforming the 340B Drug Pricing Program so that its benefits follow the patient, rather than the hospital, is also essential.
Despite these obstacles, the track record of physician-owned ASCs shows that regulatory barriers can be navigated responsibly. As healthcare costs continue to rise, a more efficient, physician-led model may become increasingly appealing to policymakers seeking cost-effective alternatives.
This vision for physician-owned hospitals represents more than just a structural change – it’s a fundamental reimagining of how healthcare can be delivered. By aligning ownership, governance, and clinical care, we create a system that better serves both patients and healthcare providers.
The success of physician-owned ASCs has already demonstrated the viability of this approach on a smaller scale. As we look to the future, expanding this model to full-service hospitals offers a promising path toward more efficient, effective, and humane healthcare delivery.
This isn’t just an idealistic vision – it’s a practical blueprint for transforming our healthcare system. As we continue to grapple with issues of cost, quality, and provider burnout, physician-owned hospitals offer a proven model for positive change. The question isn’t whether this model can work – it’s whether we have the collective will to overcome the regulatory and institutional barriers that stand in the way of this necessary evolution in healthcare delivery. It’s time we advocate for physician ownership.
“Placing blame on others is easy. Taking responsibility for yourself is empowering.”
— Tony DiCicco (1948-2017), former USWNT head coach
The threat of defunding bench research looms large over the recent pauses by the current administration. Recently, the state of Illinois unfurled a red flag with what amounts to a shutdown of funding to their state Medicaid coffers. Insurers are holding their collective breaths for the flood of capital coming if Medicare Advantage becomes the Medicare default position for people entering that age.
There is definitely a lot of collective anxiety with the uncertainties of the future of healthcare as well as in our small world of neurosurgery. Private practice has faced down a number of challenges over the past 2 decades. Many of us have gone through a swell of new clinic opening and then closing, venture capital and private equity forays into healthcare, and the government either not helping or intervening on the insurers behalf and really making things downright hard.
It is important to recall our specialty and our tradition of asking questions and challenging paradigms. Moreover, we need to hold fast to the ideals of patient safety. The prayer of Maimonides, attributed to, but no written by Moses ben Maimon in the 12th century speaks of this mandate:
“In the sufferer let me see only the human being. Illumine my mind that it recognize what presents itself and that it may comprehend what is absent or hidden. Let it not fail to see what is visible, but do not permit it to arrogate to itself the power to see what cannot be seen, for delicate and indefinite are the bounds of the great art of caring for the lives and health of Thy creatures. Let me never be absent-minded……Let me be contented in everything except in the great science of my profession. Never allow the thought to arise in me that I have attained to sufficient knowledge, but vouchsafe to me the strength, the leisure and the ambition ever to extend my knowledge. For art is great, but the mind of man is ever expanding.”
source: https://www.jewishvirtuallibrary.org/daily-prayer-of-a-physician
Here we see part of what is a very heartfelt plea to remain steadfast in treating patients the same no matter who they are, a steadfast commitment to betterment of our art, and to be in awe of how little we know and have yet to learn. It is these principles that are under threat, not just now, but for the last three decades.
Many people have come and gone, espousing HMOs as the great panacea, and then Medicare Advantage, and now private financial groups that tout efficiency but really just want to squeeze as much profit as possible and then roll-up the vestiges of what might have been a lifeline for people in the community to neurosurgical and spine care.
The best we can do is to remain dubious of people who say there is no other way to fix medicine other than ____. On social media, you will read policy wonks who openly mock physicians, lie about statistics, and then lie in front of Congress. When it comes to survival of private practice, as a member of your community, of your specialty it’s critical to be critical.
My family and I were displaced recently by the Palisades fire for over 2 weeks. We were fortunate that our home survived, unlike our unfortunate colleague Dr. Abou-Samra who lost his cherished home in Ventura not long ago. The burn came close enough that I could photograph the scar from across the street where it had stopped. We had thousands of firefighters, dozens of helicopters and fixed wing Canadian “scoopers” that fought hard right on our own block. I live near the future head of the FDA and a former governor of our state in a very modest and beloved home built during the “I Love Lucy” era. Many of my patients lost their homes and are/were displaced. Many physicians that I know and are my friends lost their homes and are trying to be strong. We continued to see patients even under evacuation. A lot us did, and I am certainly not unique in that regard.
The management of this fire was immediately subject to scrutiny and criticism that ranged from would-be candidates for mayor opining without expertise on fire or fire management to a mayor who tried unsuccessfully to refute what the fire chief had said consistently and emphatically that the department was underfunded. There is always plenty of blame to go around when stuff goes sideways.
As physicians we are pillars of our respective communities and many still look to us to be steady, even-handed, and critical of ourselves and each other. What is not critical is finger-pointing, yelling, and “owning” each other. It is this lumping and splitting that has rendered much of medicine like a drug-addled, borderline personality-toting, indecisive and ineffective clown.
I am in the middle of reading a book called “The Cancelling of the American Mind” by Lukianoff and Schott. I am not impressed by a lot of what is being touted, and can seem at times and advertisement for the law collective known as “FIRE” (https://www.thefire.org/), but does speak of building a philosophical fortress. I won’t go into a ton of detail, but the important things is by lumping and splitting each other we insulate ourselves from productive discussions and numerous topics in healthcare. This amounts to us self-gaslighting and keeping us on a hamster wheel of blame, rather than organizing, motivating, and making progress. If all we do is argue whose political party has all the answers, we will never figure this out. Truth is, there is too much money in healthcare for people in medicine to get the right thing done. Taking back agency is our best bet.
We have to remember that the only way out of the healthcare morass is to not step on one another, to engage when able, be respectful in a constructive way, teach, mentor, collaborate and remember nobody give a good Goddamn about our patients other than us.
As neurosurgeons and trainees, many of us have observed the significant cost differences between facility fees for procedures performed in inpatient settings versus outpatient ambulatory surgery centers (ASCs). These billing nuances, along with the inflated costs of services when procedures are done in hospitals, can have far-reaching implications for patients, healthcare providers, and insurers. For neurosurgeons, both outpatient surgical procedures and imaging studies are subject to these disparities in cost. In an era of ever-increasing healthcare spending, pinpointing the drivers of billing heterogeneity across different care settings (inpatient hospitals, ASCs, etc.) is crucial for improving billing transparency and driving cost reduction. In their November 2024 article, “The Curious Persistence of Site-Dependent Payments,” Barak Richman, J.D., Ph.D. (Stanford University), Elizabeth Plummer, Ph.D., CPA (Texas Christian University), and Ge Bai, Ph.D., CPA (Johns Hopkins University) unpack the socioeconomic drivers behind site-dependent payments in the U.S. healthcare system. The authors explore the issue of site-dependent payments, legislative efforts to address it, potential reasons for its persistence, the role of employers in healthcare cost management, and offer potential solutions to this complex problem.
Understanding Site-Dependent Payments
Site-dependent payments refer to the higher costs associated with a single procedure when it is performed in different settings (e.g., inpatient hospital, ASC, or freestanding physician facilities). Richman et al. highlight a study showing that private insurers may pay up to 61% more for a procedure like a colonoscopy performed in a hospital compared to an ASC. While similar data for neurosurgical procedures have not been generated, it’s easy to imagine similar cost discrepancies for procedures we commonly perform (e.g., simple decompressive or endoscopic spine surgeries, spinal cord stimulators, angiograms, etc.). Although clinical outcomes may be identical across settings, the added costs of hospital infrastructure and facility overhead contribute to the higher prices in hospital settings. These inflated costs can be hard to justify, particularly for non-complex or routine procedures, which are increasingly offered in outpatient settings.
Legislative Efforts and Challenges
There has been growing bipartisan interest in aligning Medicare payments for outpatient services across different settings, also known as creating site-neutral payments. The Lower Costs, More Transparency Act seeks to reduce these cost disparities across care settings. This bill was passed by the U.S. House of Representatives and aims to standardize Medicare drug reimbursements across settings, with an estimated savings of $3.7 billion over the next decade. However, the article points out that the bill’s passage faces significant resistance, particularly from hospital lobbying groups. Hospitals argue that their greater burden to uphold regulatory and safety standards, as well as their larger infrastructure costs, justify higher reimbursement rates—even for routine procedures. The persistence of site-dependent payments could result in disparities in physician reimbursement, affecting how neurosurgeons are compensated for similar procedures in different settings for the same Diagnosis-Related Group (DRG) code.
Key Drivers of Site-Dependent Payments and Barriers to Reform
Despite political momentum to improve payer awareness and reduce healthcare costs, the authors highlight several barriers preventing reform and offer an analysis of these persistent issues:
The Role of Employers in Site-Dependent Payments
The article also underscores the important role of employer-sponsored health plans in the persistence of site-dependent payments. Employers, who provide health coverage for over 178 million Americans, have significant influence over healthcare costs. However, the authors point out that many employers fall short of effectively managing or negotiating the value of healthcare benefits for their employees. Often, human resources departments focus on employee satisfaction rather than healthcare cost optimization. Furthermore, employers tend to rely heavily on third-party brokers and consultants, whose incentives may not align with reducing healthcare costs or delivering value-driven care. This misalignment can result in patients facing higher out-of-pocket costs, potentially limiting access to surgical care.
Potential Solutions and Reforms
While broad modifications to reimbursement models are necessary, the authors suggest that solutions may lie in “buy-side” reforms, which involve engaging employers to become more strategic and demanding when making healthcare purchasing decisions. For example, coalitions of large employers, such as the National Alliance of Healthcare Purchaser Coalitions, are already pooling resources to create strategies aimed at improving the value of healthcare benefits for employees. These coalitions work to push for more transparent pricing and cost-effective solutions, which could eventually reduce the prevalence of site-dependent payments and drive down costs across the healthcare system. For neurosurgeons, this shift could result in more favorable reimbursement rates, as employers begin to demand more efficient and value-based care, which could, in turn, impact surgical care reimbursement structures.
Additionally, the authors note that legal and regulatory mechanisms, such as the Employee Retirement Income Security Act (ERISA), may play a crucial role in policy reform and the implementation of site-neutral payments. ERISA mandates that employers act in the best financial interests of their employees when providing health benefits. The article points out that recent lawsuits under ERISA could signal a growing trend to hold employers accountable for wasteful healthcare spending. These legal pressures may encourage employers to demand better value in healthcare purchasing, ultimately driving down unnecessary costs. For neurosurgeons, this could have significant implications for how health plans manage surgical procedures and reimbursements, especially as they focus more on cost-efficiency and value.
Conclusion
The nuanced economic practices that have led to the persistence of site-dependent payments are rooted in historical payment structures, hospital monopoly power, and inefficiencies in employer healthcare purchasing. For neurosurgeons, understanding the ramifications of continued site-dependent payments is crucial as we navigate an evolving healthcare landscape. Reimbursement structures may shift in response to regulatory changes, employer-driven reforms, and market pressures. By advocating for more value-driven care and engaging in broader healthcare cost reform efforts, we can help ensure that patients receive high-quality care at more affordable prices.
References:
Site Neutral Payments: A Critical Step Toward Restoring Physician Independence
Anthony DiGiorgio, DO, MHA
Dr. Campos has provided an excellent analysis of site-dependent payments and their impact on healthcare costs. Building on her thoughtful review, I would like to emphasize how this payment disparity particularly affects physician autonomy and practice independence.
The defense of site-dependent payments by hospital systems represents a striking example of how large healthcare institutions protect their revenue streams, regardless of the impact on healthcare delivery and cost efficiency. Consider a straightforward neurosurgical procedure like a lumbar laminectomy: hospital outpatient departments receive approximately 40% more in reimbursement than ambulatory surgery centers for the exact same procedure. This disparity defies logical explanation.
To put this in perspective, imagine paying a 40% premium for an identical hamburger solely because it was prepared in a large chain restaurant rather than a local independent establishment. The chain’s justification? Their corporate overhead and operating costs are higher. Most consumers would reject such pricing logic outright, yet Medicare’s payment system continues to reward this inefficiency by providing higher reimbursements to large hospital systems.
This situation presents a notable paradox within healthcare reform. Proponents of the Affordable Care Act argued that consolidation would increase efficiency and reduce costs. However, the justification for site-dependent payments directly contradicts this premise – large hospital systems claim they need higher reimbursements precisely because they are less efficient. This logical inconsistency undermines the fundamental goals of healthcare reform and cost containment.
Implementing site-neutral payments – where procedures receive the same reimbursement regardless of setting – represents a crucial step toward restoring physician independence. When physicians who own ambulatory surgery centers or perform in-office procedures receive equivalent reimbursement to large hospital chains, it creates a more level playing field. This equity in payment could help reverse the trend of private practice consolidation and preserve physician autonomy in healthcare delivery.
The current system’s bias toward hospital-based care not only increases costs but also accelerates the erosion of independent medical practice. By advocating for site-neutral payments, we support both cost-effective care delivery and the preservation of physician independence – two essential elements for a sustainable healthcare system.