American hospitals are having another crisis: nursing shortages. One of my hospitals has over 500 traveling nurses working there, while another has nearly 100. The “great resignation” has hit public hospitals the hardest, with their inability to pivot quickly and be competitive by raising wages as rapidly and as much as non-public hospitals can do. Southern California public hospital nurses are being offered as much as a $20/hour raise to change jobs, so it is not hard to imagine what they see in their best interest. Those hospitals lucky enough to have nursing training programs can hire some of their own graduates, but these new graduates can also write their own tickets as soon as they get some experience under their belts, causing a revolving door. In one of my tertiary care hospitals, we have declared an “internal disaster,” the worst consequences of which include shutting down elective surgery and outpatient clinics so those nurses can be reassigned to inpatient responsibilities and stopping the acceptance of outside hospital transfers (with exception of trauma and stroke). I can’t remember a time in my 25-year career when nursing shortages were so acute, and there were so many negative consequences for our tertiary care hospitals, on which so many smaller hospitals depend for subspecialty support. Of course, the smaller hospitals are also facing this nationwide nursing shortage.
What can our hospital and medical staff leaders do to address the nursing shortage in an economy with full employment? Will this be a short-term problem, or is this the new normal? This may be the time for our leadership to consider new and swift international collaborations to address our nursing shortages. Can California import nurses from countries with a surplus or expand collaborations with countries like the Philippines that specialize in training nurses for the entire world? Can we expedite nursing recruitment from our neighbors: Canada and Mexico? Apparently, there are mechanisms in place for a fast track for international nurses, but the logistics are still daunting, and we are clearly behind the curve and falling fast.
While our nursing shortage is not new, it is at crisis levels now and will most likely deteriorate for years to come. Neurosurgery is not an island, and the nursing limitations affect us in the ER, the OR, the ICU, the clinic, the angio suite, and the wards. While we may not be able to influence their choices, I do want to take this opportunity to personally thank all the nurses that played a critical role in serving our patients (sometimes at high personal risk, such as during COVID-19 and even before), in advancing my education, in assisting our residents, in rescuing me from poor clinical judgments while a junior physician, and as the most enduring co-champions for our patients. We hate to see you go–we have been in the trenches together, and your absence is being felt both professionally and personally; thanks for everything. For those nurses who continue on their jobs and continue to fight the good fight, we appreciate you.
In this issue, we have a first … “Letters to the Editor.”
The editorial committee and I always ask for and welcome comments about and critiques of our publication. Well, this month, we received two “letters to the editor.” They are listed in the order they were received. The first is complimentary, but the second is critical. Both came from admired and respected colleagues. The editorial committee and I appreciate and encourage all of you to express your opinion in the form of letters to the editor. We will publish them.
Our colleagues Praveen Mummaneni and Anthony DiGiorgio wrote about some concerns regarding AB 35, a bill that was signed by the Governor; it is called the MICRA Modernization Act and is said to stabilize the malpractice market and introduce a Collaborative Just Culture approach.
The ”Women in Neurosurgery” column is written by our own Deborah Henry; she recalls her experiences during her residency days thirty years ago. Attitudes have since changed, but gender equity remains a concern. She offers a practical and common sense approach to resolving gender discrimination.
We are grateful to Katie Orrico, Senior Vice President of Health Policy and Advocacy, AANS, and CNS, for updating up on the latest ruling regarding Surprise Billing issued on August 19.
Included in this issue is the list of board members of the NeurosurgeryPAC for the calendar 2022-2023. You will note that California is well represented. Kenneth S. Blumenfeld, MD, Vice Chair, Mark E. Linskey, MD, Anthony DiGiorgio, DO, MHA, Brian R. Gantwerker, MD, Praveen V. Mummaneni, MD, Anand Veeravagu, MD, John K. Ratliff, MD are excellent ambassadors. The NeurosurgeryPAC, as you know, is our nonpartisan advocacy group. Led by Katie O. Orrico and Adrienne Mortimer from the Washington Office, it is at once an effective and respected group in the halls of Congress. We are all encouraged to lend your financial support.
The usual columns are included. Additionally, there is an important article from Medscape News titled “Physicians’ Medicare Pay Keeps Dwindling ― How Bad Will It Get?” In it, John Ratliff and many others are quoted. I encourage you to read it.
The photo of the month was taken by Deborah Henry during a recent trip to the Europe. It is of Drop Zone Y, where the British 4th Brigade landed near Arnhem, the Netherlands, on September 18, 1944.
Please note that in addition to the newsletter, you will receive in a separate attachment a call for nominations for next year’s CANS board. Please address your responses to the chair of the nominating committee, Mark Linskey. Your voice is important.
As always, we welcome your comments and critiques. Please contact me directly at firstname.lastname@example.org, or call me on my cell phone: 805-701-7007.
On May 23, 2022, Governor Newsom signed AB 35. This legislation aimed to modernize the Medical Injury Compensation Reform Act (MICRA). California physicians are familiar with MICRA and its protections against egregious non-economic damage claims in malpractice tort cases. AB 35 increases the existing $250,000 cap incrementally until it reaches $750,000 (or $1,000,000 if wrongful death is involved). It does introduce some new protections, however: for example, when the bill becomes effective pre-litigations expressions of sympathy or regret by a physician are protected.
AB 35 was a compromise, as the “Fairness for Injured Patients Act” was set to be on the November 2022 ballot. This would have eliminated the MICRA caps altogether, and California physicians faced an expensive campaign to defeat it. AB 35 was passed with the support of the California Medical Association as a compromise measure, stopping the ballot initiative in exchange for a more moderate legislative proposal.
While this compromise saves that legal fight, the effects of AB 35 are yet to be determined. Work by our group, which was presented at the 2021 AANS national meeting,1 shows the effects of various tort reform laws on the malpractice insurance premium rates, malpractice claims rates, and per capita neurosurgeon compensation across states. The only reform that had a statistically significant effect was the presence of a cap on non-economic damages. This lowered malpractice premiums.
Further work by our research group examined the effects of the malpractice environment on outcomes after spine surgery.2 We found that environments with a higher risk of malpractice claims correlated with longer length of stay, increased chances of a non-home discharge, and higher overall charges. Despite this, there were no differences in mortality rates in the more high-risk states.
California neurosurgeons are right to be concerned about AB 35. As the specialty with the highest malpractice claim rate, we are likely to feel any ill effects of this bill most acutely. Malpractice premiums will undoubtedly rise. Increasing claims will also lead to more defensive medicine, with an increasing cost of providing care. It could lead to less access to care for patients, especially if neurosurgeons do not feel that covering emergency calls will be offset by the increased liability exposure.
The effects of this bill must be monitored closely. We know CANS will continue to do so and to continue advocating for California neurosurgeons.
I believe in free will, but with some … limitations.
OK, let me admit that I was born and raised in a culture where most people strongly believe in predestination. This is not something inherent to the Middle East; it has been addressed by several Christians and western philosophers. And without making this a religious essay, I’d like to be clear: I do not agree with John Calvin’s Doctrine on predestination, or as some describe it, double predestination. Just to refresh your memory, Calvin believed that “it is God’s sovereign decision to determine whether an individual is saved or damned.” This clearly takes “free will” out of the equation.
I firmly believe I can choose right from wrong and am responsible for my choices. If I do something wrong, I should face the consequences. But I still believe that, in general terms, my life was predestined.
Some say that if you believe in predestination, you become lazy. Why work hard? Que sera, sera!
I don’t believe this to be correct. I have been retired for five years but still wake up at five in the morning as if I had to start surgery at 7:30. I am always looking for things to do, and I manage to stay busy. My genetic make-up does not include laziness.
In addition to genetic make-up, social upbringing, educational background, and occupational exposure work together to determine who we are and how we behave. Is our choice a major factor in any of these influencers?
I propose that if you look back at your own life, you will find that you had a minor say in all the major milestones in your life.In my case, consider this:
I think I should stop here …
I hope that you can clearly see that in my case, when it came to the major milestones of my life, I had a minor role in the decision-making: I simply chose what was put in front of me. The late Archbishop Desmond Tutu essentially agreed when he said: “There are no self-made men. People helped to shape me.”
Yes, our genetic make-up, our family upbringing, our social encounters, our education, and sometimes pure Providence act collectively, like the proverbial rose-colored glasses: they help us see things from our own perspective and influence the way we exercise our “free will!”
June was my 30th graduation anniversary from my neurosurgery residency. Hard to believe that in three years, it will be my 30th anniversary of becoming the 35th female Diplomate of the American Board of Neurological Surgeons. A lot has changed for women in that time. A lot still needs to change.
As a minority in residency, I stuck out like the proverbial sore thumb. When things went right, no one was recognized. If I was even remotely related to something that went wrong, I was the one people remembered. After all, I looked nothing like the other male residents who blurred together in the eyes of the hospital staff. My saving grace was passing my ABNS written boards in my junior year of residency. Immediately, I went from a female oddity to validation as a female intelligent enough to become a neurosurgeon.
My residency was in the days of the 100+ hour workweek, where the adage was that if you were at home every other night, you were missing half of the good cases. The detriment of making medical errors because of sleep deprivation or nodding off in the OR as the second assistant was balanced with the education from the continuity of patient care. Patients were admitted the night before surgery, giving all residents the crucial experiences in history-taking and neurological examinations and the review of X-rays, CT scans, and the relatively new MRI with attending physicians. I am old enough to remember those UBO’s-unidentified bright objects-as a common MRI interpretation.
Six years ago, I attended my 30th anniversary of graduation from Baylor College of Medicine. Our class was 1/3 female students. Several of us went into surgical fields, including general surgery, otolaryngology, and urology. The general surgeon who was at the reunion had left her field and was practicing emergency medicine. The ENT surgeon, who was an academic physician, commented on her findings showing that women residents finished with significantly fewer cases than their male counterparts. The urologist….well, I think she had a harder time than I did. I sensed bitterness as they discussed their 30-year careers. There was a want for respect for who they were and what they had accomplished.
Being a trailblazer is never easy. Many constantly doubt your abilities. Others never change their opinion that neurosurgeons must have XY chromosomes to be competent.
How do we curb gender discrimination? The simple answer is to treat women and men equally. Same pay, the same family leave, same opportunities-starting with caseloads and names on research papers during residency. Promote women in leadership positions. As of this year, the AANS has elected its second woman neurosurgeon president (Louise Eisenhardt, neuropathologist, also served when the AANS was the Harvey Cushing Society). The Western Neurosurgical Society and CANS each have had one woman president, and the Congress of Neurological Surgeons has none to date. Encourage capable women neurosurgeons to become department chairs (currently 5) and program directors.
Embrace change. Be a mentor. Don’t make assumptions. Ask questions. But don’t ask the sole woman in the room to make the coffee, hotel reservations, or take secretarial notes unless she offers. I’ve been there.
Gender Equality in Neurosurgery and Strategic Goals Toward a More Balanced Workforce
Neurosurgery: May 2022 – Volume 90 – Issue 5 – p 642-647
One hundred years of neurosurgery: contributions of American women
Journal of Neurosurgery Volume 134: Issue 2, 2008 https://doi.org/10.3171/JNS/2008/109/9/0378
Loma Linda University, the oldest academic medical center in the inland empire region of California, started as a missionary hospital. The medical school was opened in the early 1910s, as envisioned by the prophet Ellen G. White. The medical institution’s mission of providing whole-person care is based on the guiding principles of the Seventh-day Adventist faith. Since its foundation, over the last 100 years, the University’s history has been marked by several renowned medical high points. In 1984, Baby Fae, an infant born with a congenital cardiac abnormality, received a baboon heart transplant, the world’s first successful xenotransplant in an infant. In 1990, LLU pioneered the building and use of the first proton beam accelerator on the west coast, which has been instrumental in delivering advanced cancer care and furthering research in radiation treatment globally.
The neurosurgery program at LLU was started by Dr. George Austin, who after training with Wilder Penfield at the Montreal Neurological Institute (MNI) moved to the inland empire region to create an academic practice. Dr. Austin transferred the neurosurgery practice at the Hospital of Medical Evangelists, in downtown Los Angeles, to where it is today in Loma Linda. He recruited several other neurosurgeons including Dr. Robert Knighton and a medical student Dr. Lloyd Dayes. Dr. Dayes, a graduate of the LLU School of Medicine, was one of the first African American board- certified neurosurgeons in the country. He also did his neurosurgical training at the MNI and eventually returned to LLU where he practiced for the following three decades. The department has a storied history of providing advanced neurosurgical care in Southern California. In the early 1970s, Dr. Austin invited neuroscientists from all over the world to LLU to research and refine cerebral bypass techniques. Following Dr. Austin, the department was successively led by Dr. Knighton, Dr. Dayes, Dr. David Knierim, Dr. Shokei Yamada, Dr. Wolff Kirsch, and Dr. Austin Colohan.
In line with the academic mission of the institution, the neurosurgical residency program at LLU received its initial approval in 1969 and has since graduated several dozen neurosurgeons. The academic mission of LLU is also reflected in its commitment to research accomplishments. The institution historically has secured numerous NIH grants and continues to work actively on nationally funded projects in cerebrovascular research led by Dr. John Zhang and Alzheimer’s disease research directed by Dr. Kirsch.
The current chairman, Dr. Warren Boling, took over the leadership of the department in 2015. The department has since grown to its current status of a premier quaternary care and referral center for neurosurgical care in the inland empire. The department provides its services at LLU, which opened a new state-of-the-art medical center in 2021, Riverside Community Hospital, Loma Linda VA Medical Center, and Desert Regional Medical Center in Palm Springs. More than 3000 operations are performed annually across all neurosurgical subspecialties, serving the diverse populations of both San Bernardino and Riverside counties.
I was fortunate to give the first-ever community grand rounds for the UCSF department of neurosurgery. This session invited community members to an online forum where they could ask questions and participate in polling. Dr. Praveen Mummaneni moderated, and I spoke about spinal neurotrauma, covering both spinal cord injury and minimally invasive approaches to spinal trauma. The video is available on YouTube here.
This was a huge honor. I am proud of the research into spinal cord injury and novel surgical management of spinal trauma being undertaken at UCSF. I hope that people found the grand rounds informative. Of course, there was not ample time to discuss my other passion: CANS (and policy, socioeconomics, etc.) In planning the grand rounds, we discussed a combined policy & spinal cord injury discussion. Alas, that would not have done justice to either topic.
Readers of the column hopefully know the extent of my love for socioeconomic and policy research. I have no doubt I can fill an hour-long grand rounds on policy as well. Thankfully, I have many outlets for my work in that field: this column, my work on the CSNS newsletter (check that out here), and a smattering of invited commentaries. Please forgive the continual humblebrag in this column. (I will admit I was quite nervous regarding the grand rounds, and this piece is rather cathartic.)
I consider myself lucky to have such research passions. Even more than that, I am privileged to work at an institution that fosters both.
The resources available for my interests at UCSF are unparalleled. I have ample assistance navigating IRB protocols and device regulations. There is data analysts and statistics support. I am humbled by the cadre of incredibly intelligent and hard-working residents, medical students, and pre-med students who share my interests. I can only hope to mentor those students much as my mentors have guided me.
So, this just makes for a long-winded footnote to my grand rounds; a thank you to the institution which has provided me with such resources and support, gratitude to the tireless medical students who make the research seem easy, and appreciation to institutions like CANS and CSNS that let me have a voice in policy.
John Ratliff, MD, a neurosurgeon at Stanford University, is tired of the way the Medicare program keeps paying physicians less and less.
Physicians are facing a planned 8.42% cut in Medicare reimbursements in 2023, which would be on top of a 2.75% cut in the second half of this year and a 3.3% cut in 2021.
“This constant cutting of Medicare rates, which has been going on for years, makes it hard for practices to make ends meet,” said Ratliff, who chairs the Washington committee of the American Association of Neurological Surgeons and the Congress of Neurological Surgeons.
Uncertainty about what the actual 2023 cut will be makes it hard for practices to plan ahead. At the end of this year, just before the cut is scheduled to go into effect, Congress might pare it back significantly, as it did the past 2 years. “These last-minute changes create a lack of stability and a lack of clarity for our practice environment,” Ratliff said.
Will Congress step in again? The past last-minute fixes by Congress were seen as ways to protect physicians from the financial impact of the COVID-19 pandemic. But some policymakers think practices have now recovered and don’t need another financial rescue.
“Medicare’s payments for clinician services are adequate,” stated the Medicare Payment Advisory Commission (MedPAC) in its March report https://www.medpac.gov/wp- content/uploads/2022/03/Mar22_MedPAC_ReportToCongress_SEC.pdf. “We expect volume and revenue to rebound to pre-pandemic levels (or higher) by 2023.”
A coalition of some 120 physicians’ groups, including the American Medical Association (AMA), disputes that view and is calling for an overhaul of the way Medicare adjusts physician pay.
“The constant yearly fixes are ridiculous. It reminds me of the SGR,” Ratliff said, referring to the sustainable growth rate, an automatic adjustment that menaced Medicare physician payments for the first one and a half decades of the 21st century. In all but 1 year, Congress stepped in to undo the yearly SGR cut, often weeks before it was due. The SGR was abolished in 2015, but the annual scenario seems to be back.
Hyperinflation in the economy will make Medicare pay cuts seem even steeper. In June https://www.bloomberg.com/news/articles/2022-07-13/us-inflation-accelerates-to-9-1-once-again-exceeding- forecasts, the general inflation rate stood at 9.1%, the highest level in more than 40 years, according to the US Department of Labor. In late spring https://www.healthsystemtracker.org/brief/overall-inflation-has-not-yet-flowed- through-to-the-health-sector/, gas prices were up 43.6%, while prices for medical care rose just 3.2% over past year.
Although gas prices have recently been dropping, the rising gas prices have taken a toll on practices. “The gas price forced one person on my staff to quit,” said David L. Holden, MD, an orthopedic surgeon in Oklahoma City. “She needed child care to come to work, and the cost of gas was so high she couldn’t afford the child care anymore,” added Holden, who is president of the Oklahoma State Medical Association.
According to Holden, continued Medicare payment cuts could lead to access problems for patients. “If reimbursements continue to drop, more doctors will have to cut back on Medicare or even drop it,” he said.
A Long-Term Slide in Medicare Payments
“The problems physicians are having with Medicare cuts are not new. We have been experiencing them for more than two decades,” said Parag D. Parekh, MD, an ophthalmologist in State College, Pennsylvania, and chair of government relations at the American Society of Cataract and Refractive Surgery.
From 2001 to 2020, the cost of running a practice rose 39%, but Medicare payments, adjusted for inflation, fell by 50% https://www.surgicalcare.org/wp-content/uploads/2022/07/SCC_FactSheets_Medicare_101_Surgeons.pdf, according to the Surgical Care Coalition, a group of surgical societies that opposes the Medicare cuts.
Even without accounting for inflation, Medicare reimbursements for doctors are at the same level as two decades ago. The Medicare conversion factor, a multiplier used to convert relative value units (RVUs) into the reimbursement amount, stood at $36.69 in 1998, and this year it stands at $34.60, the coalition reports https://www.surgicalcare.org/wp-content/uploads/2022/07/SCC_FactSheets_Pressures.pdf.
“Medicare payments to hospitals have a 2% yearly increase built in, but doctors don’t have that,” said Ezequiel Silva III, MD, a San Antonio, Texas, radiologist who chairs the Relative Value Scale Update Committee, operated by the AMA.
This may also be due to the unique position the SGR put physicians in. The SGR was supposed to regulate physician fees. When Congress abolished it in 2015, it transitioned physicians to value-based payments, which basically reward them for saving money for Medicare. This is done either through the Merit-Based Incentive Payment System or Advanced Alternative Payment Models (APMs).
After the SGR was abolished, physicians received modest yearly increases of 0.5% or less for 5 years, but, owing to other factors, actual reimbursement was lower than that amount. Since 2020, physicians have received no updates at all. In 2026, an even more modest increase of 0.25% is scheduled to begin https://bulletin.facs.org/2019/09/medicare- physician-payment-on-the-decline-its-not-your-imagination/.
Working Harder to Compensate for Lower Payment
“As physicians saw the real payment for their work decline, the answer often was, ‘All right, I’m going to work harder,’ but you can only work so much harder,” said Brian Larkin, MD, a hip and knee surgeon at Orthopedic Centers of Colorado in Denver.
Larkin added that doctors have had to become more efficient, but they are often not rewarded for that by Medicare. “I have been doing hip and knee replacements in a very efficient, cost-effective way,” he said. He has been participating in Medicare’s Comprehensive Care for Joint Replacement Model, which has been rewarding hospitals for improved cost efficiency. But Larkin said the program did not reward doctors for using markedly less expensive ambulatory surgery centers rather than hospitals.
Through his value-based activities, Larkin had hoped to qualify for Medicare’s APM program, which would have rewarded him a 5% bonus. To qualify, however, he would have needed to have received at least 50% of his Medicare payments or to have 35% of his Medicare patients on a qualifying APM, but Larkin said not enough Medicare programs are available to reach that level.
“APMs sound good on paper, but they don’t have practical meaning in terms of benefiting providers,” Larkin said. His concerns about getting the 5% bonus will soon be moot, however, because 2022 is the final year to qualify for it.
When Payment Rises in One Area, It Must Fall Everywhere ElseOne major problem with Medicare physician payments is the principle of “budget neutrality,” which basically means that whenever reimbursement is raised for one service, payment for other services must be reduced. Specifically, when the rate of an RVU is raised by a certain amount, the overall conversion factor has to be reduced to account for that extra spending.
In 2021, primary care groups won concessions in their long-standing campaign to raise their reimbursements. The RVUs assigned to key evaluation and management (E/M) codes were raised significantly. For example, the work RVU for a visit by an established patient rose 34% https://www.mgma.com/resources/financial-management/restoring-balance- 2021-e-m-changes-and-the-elephan.
“The E/M changes gave more money to primary care,” Parekh said. “But due to budget neutrality, money had to be taken away from the proceduralists.”
Parekh said the Centers for Medicare & Medicaid Services (CMS) could have softened the blow to surgeons by raising the value of the E/M component of their global surgery codes, but it did not do so.
“Budget neutrality can have the effect of pitting physicians against each other,” Parekh said. “But all doctors’ groups are united in their belief that budget neutrality must end.”
The Perils of More Congressional Cuts
CMS sets Medicare reimbursement each year, but Congress has been adding reductions to the CMS cuts. CMS has proposed a 4.42% cut for physicians in 2023, but the expected cut is actually 8.42% because an automatic 4% cut goes into effect when federal spending reaches a certain level. This cut is directed by Congress through the Statutory Pay-As-You-Go (PAYGO) Act of 2010.
PAYGO cuts were triggered by the American Rescue Plan Act of 2021, a $1.9 trillion package to offset the effects of the COVID-19 pandemic. If allowed to go through, the 4% PAYGO cut would affect all discretionary spending by the federal government, not just Medicare. These cuts were supposed to start in 2021, but Congress set them aside for 2021 and 2022.
Will Congress set PAYGO aside for 2023? Interest groups on Capitol Hill, including physicians’ groups, are asking for another year’s deferral, but PAYGO cuts will probably occur sometime in the future.
Another congressionally mandated cut is not counted in the 2023 cuts because it went into effect in 2022 and therefore is not considered a new cut. The Medicare sequestration is a 2% cut on all Medicare payments, not just those for physicians.
The 2% Medicare sequestration cut was in effect from 2012 to 2019, but Congress set it aside in 2020 and 2021 because of the pandemic. It phased it back in for this year. Is the Medicare sequestration here to stay, or can Congress be convinced to set it aside again?
“Now is a bad time for cuts, when inflation is so high and we just came out of a pandemic,” said Issada Thongtrangan, MD, a solo orthopedic spine surgeon in Scottsdale, Arizona. “Practice costs are going up and they keep cutting reimbursements.”
What Lies Ahead
Physician groups want Congress to go beyond simply overriding planned cuts every year. “Unless there is a fundamental change in the payment system, Medicare physician pay will likely be cut every year into the foreseeable future,” said George Williams, MD, an ophthalmologist in Royal Oak, Michigan, who is a spokesperson for the American Academy of Ophthalmology.
Budget neutrality, as it exists now, produces cuts whenever the value of services is significantly changed. The AMA is calling on Congress https://www.ama-assn.org/practice-management/medicare-medicaid/10-principles-fix- medicare-s-unsustainable-physician-pay to “eliminate, replace, or revise budget-neutrality requirements to allow for appropriate changes in spending growth.”
The AMA also wants physicians to have a reliable payment update. “The physician payment system needs to provide predictable and dependable annual increases that take into account inflation and rising practice costs,” said Jack Resneck, Jr, MD, a San Francisco dermatologist who is the 2022-2023 AMA president.
Furthermore, the AMA wants physicians to be able to participate in Medicare payment models that “recognize physicians’ contributions in providing savings and quality improvements, such as preventing hospitalizations,” according to an AMA report https://www.ama-assn.org/practice-management/medicare-medicaid/10-principles-fix- medicare-s-unsustainable-physician-pay.
In Resnick’s words, “Physicians are extraordinarily dissatisfied with the way Medicare pays them.”
The CMA Board of Trustees took the following action on the Recommendations in the report from the Council on Ethical, Legal and Judicial Affairs
RECOMMENDATION 1: 501-21: Resolution to Condemn State-Sanctioned Torture of Detained Migrant Children
RESOLVED: That the CMA also publicly recognize that the treatment of these children is consistent with internationally recognized definitions of torture and as such cannot be tolerated in the United States, and,
RESOLVED: That the CMA recognizes that the detention of migrant children may threaten their short- and long-term health; and be it further
RESOLVED: That the CMA call for opposes an immediate end to the practice of separating migrant children from their families; and.
RESOLVED: That CMA call for immediate closure of all all migrant child detention centers and the release of these children to relatives or appropriate community foster care as stipulated by the Flores Agreement, and,
NEW RESOLVED: That the CMA supports the preferential use of alternatives to detention programs that respect the human dignity of immigrants, migrants, and asylum seekers who are in the custody of federal agencies.
RESOLVED: That this be referred for national action.
Board action: Approved recommendation as amended
August 1 – California’s governor Gavin Newsom declared a state of emergency to speed efforts to combat the monkeypox outbreak, becoming the second state in three days – after New York State – to take the step. Nearly 800 cases of monkeypox have been reported in California, according to state public health officials. California is usually in the lead.
August 2 – Vin Scully the voice of the LA Dodgers for 67 wonderful years, a legendary broadcaster, a poet, a gifted storyteller, a wonderful human, a role model, a friend, and a father and grandfather figure to millions of fans, dies at age 94. Ace pitcher Clayton Kershaw said it best: “Vin Scully was the best there ever was.”
August 3 – From FP – French mayor Jean-Marc Peillex—whose town of Saint-Gervais-les-Bains is a favored launch point for mountain climbers looking to climb France’s highest peak, Mont Blanc—has called for future adventurers to first pay a 15,000-euro deposit to cover the costs of rescue (or their demise). Peillex has decried the rise of “pseudo- mountaineers” who he says are putting too much strain on local authorities. “People want to climb with death in their backpacks,” Peillex wrote on Twitter. “So, let’s anticipate the cost of having to rescue them, and for their burial, because it’s unacceptable that French taxpayers should foot the bill.” A man driven by common sense.
August 3 – Richard Damadian, creator of the first M.R.I. scanner, dies at 86. Dr. Damadian and his research assistants finished building the first M.R.I. scanner more than 40 years ago. Originally known as a nuclear magnetic resonance scanner, or N.M.R., its first scan, on July 3, 1977, was of Lawrence Minkoff, one of Dr. Damadian’s assistants — a vivid and colorful image of his heart, lungs, aorta, cardiac chamber, and chest wall. We can’t even imagine Medicine, Surgery, Neurosurgery, Neurosciences, and scientific research without this technology.
August 4 – The Biden administration declared the growing monkeypox outbreak a national health emergency, a rare designation marking just the fifth such national emergency since 2001. The declaration by Xavier Becerra comes as the country remains in a state of emergency over the coronavirus pandemic. The World Health Organization declared a global health emergency over the outbreak late last month.
August 5 – To help fund the United States government during the Civil War, President Abraham Lincoln signed a new tax law on this day in 1861. With the help of Republicans in Congress, the nation’s first income tax was born. Congress levied a 3% tax on annual income over $800. Back then, laborers worked 10 hours a day, six days a week, and were off on Sunday. They were paid 10 cents an hour or 300 dollars a year.
August 6 – Fifty-seven years ago, President Lyndon B. Johnson signed the Voting Rights Act. The full title was: “An Act to enforce the fifteenth amendment to the Constitution, and for other purposes.” The title explained the need for this law. Although this law may not be needed here in California because we honor it, it remains to be necessary for many other states.
August 10- Seven years after its debut in Italy, Domino’s American Pizza Company has formally shut its stores after it failed to win over locals. I guess Italians did not like pineapple pizza and preferred the homegrown variety.
August 11 – The Centers for Disease Control and Prevention loosened Covid-19 guidelines on Thursday, freeing schools, and businesses from requiring unvaccinated people exposed to the virus to quarantine at home. In addition to eliminating quarantines, the new guidelines put less emphasis on social distancing, routine surveillance testing, and contact tracing. As the numbers stabilize and start going down, hopefully, this means that this pandemic is becoming more of an endemic and less of a concern.
August 15 – CNN – Thousands of mental health therapists are set to strike in California today. The unionized psychologists, therapists, chemical dependency counselors, and social workers are demanding that Kaiser Permanente – the country’s largest nonprofit HMO – provide “desperately needed” services to its patients, claiming that some wait months for needed therapy sessions. According to the National Union of Healthcare Workers, Kaiser staffs about one full-time mental health clinician for every 2,600 members, leading to therapists leaving Kaiser at a record rate. Please read “The Rise and Potential of Physicians Unions” in JAMA online, published July 28, 2022.
August 16 – The United Kingdom became the first country to approve a new COVID-19 booster shot designed to combat the Omicron variant BA.1 and will begin rolling it out this fall. The so-called bivalent vaccine, developed by Moderna, is not expected to produce high protection from the currently prevalent BA.5 variant. It seems we are still a step behind this virus.
August 16 – The F.D.A. will allow hearing aids to be sold over the counter, removing a barrier for millions of Americans who have not previously sought help. What did you say?
August 16 – President Biden signed into law the Inflation Reduction Act. It is a substantial piece of legislation that will make big investments in the environment and health care, increase taxes on some top earners and corporations, and … reduce the deficit. Why were insulin prices not capped at $35 for private insurers?
August 17 – A federal judge ruled that Walmart, CVS, and Walgreens must pay a combined $650.6 million to Lake and Trumbull Counties in Ohio for damages related to the opioid crisis. Opioids have become synonymous with EVIL. Is it any wonder that physicians are afraid to prescribe opioids even when necessary?
August 19 – California’s unemployment rate fell to 3.9% in July, the lowest since 1976. Employers in the nation’s most populous state continued to defy expectations by adding 84,800 new jobs. We can use good news here in the Golden State!
August 22 – Governor Gavin Newsom vetoed a measure that would have allowed the creation of safe drug- consumption sites in three major California cities as part of an effort to cut the surging number of fatal overdoses. Newsom suggested the clinics might actually encourage illegal drug use. The measure passed California’s state legislature in early August after nearly two years of debate.
August 22 – CNN – Dinosaur tracks from around 113 million years ago have been revealed at Dinosaur Valley State Park in Texas due to severe drought conditions that dried up a river. “Most tracks that have recently been uncovered and discovered at different parts of the river in the park belong to Acrocanthosaurus. This was a dinosaur that would stand, as an adult, about 15 feet tall and (weigh) close to seven tons,” park spokesperson Stephanie Salinas Garcia said in an email. This is a definite silver lining in an otherwise sad drought condition.
August 23 – The San Diego Zoo Safari Park on Monday announced the arrival of a male white rhino born to a first-time mother, Livia, at the Nikita Rhino Resource Center. Happy news for a change.
August 24 – Germany is starting hydrogen-powered trains in Lower Saxony. The trains are emissions-free and low-noise, with only steam and condensed water issuing from the exhaust. They have a range of 1,000 kilometers (621 miles), meaning they can run for an entire day on the network on a single tank of hydrogen. Such a piece of good news for the environment.
August 24 – California Air Resources Board issued a rule requiring that all new cars sold in the state by 2035 be free of greenhouse gas emissions like carbon dioxide. The new policy may accelerate the global transition toward electric vehicles. California is the largest auto market in the United States. A very ambitious goal.
August 24 – Mack Rutherford, 17, landed in Sofia, Bulgaria, on Wednesday, ending a 30-country, 30,000-mile journey and becoming the youngest pilot to circle the globe alone in a small plane. Impressive young man.
August 25 – Governor Gavin Newsom announced the appointment of Dr. Diana Ramos as California Surgeon General. Dr. Ramos has expertise in health equity and reproductive health. She currently serves at the California Department of Public Health’s Center for Healthy Communities, overseeing the state’s public health and prevention programs. The Governor created the role of Surgeon General in 2019 on his first day in office. His latest health-related action was the signing of AB 35.
August 28 – A Mickey Mantle baseball card from 1952, his rookie year with the Yankees, was sold at auction for $12.6 million. This is record-breaking, making this card the most valuable sports collectible in the world. Mantle, born in Spavinaw, Oklahoma, spent 17 years playing for the New York Yankees and was inducted into the Baseball Hall of Fame in 1974.
August 29 – NASA called off the scheduled launch of Artemis I, the first NASA trip to the moon in 50 years, because of an engine issue. I was very disappointed that the launch was postponed, but I am glad we are resuming our moon exploration. Artemis, the daughter of Zeus and the twin sister of Apollo, is the goddess of the hunt!
August 30 – The International Day of the Disappeared. It is a good idea to reflect on the hundreds of thousands of people who are missing worldwide due to armed conflict, violence, disasters, and migration.
August 31 – The Food and Drug Administration authorized the first redesign of coronavirus vaccines since they were rolled out in late 2020, setting up millions of Americans to receive new booster doses targeting Omicron subvariants as soon as next week. I plan to get it as soon as it becomes available to me.
August 14, 2022
Dear Dr. Abousamra,
It has now been seven months since you took over as the full-time new CANS newsletter and I wanted to take a moment to thank you for your hard work and efforts and a terrific job so far. Taking over from a true neurosurgery newsletter icon such as Dr. Randy Smith is never an easy task, but I think that you have made an excellent start. The newsletter is expanded in scope and content reflecting your new ideas, vision, and input. In terms of new editions, the historical vignettes are very interesting and will serve as archival resources for CA neurosurgery and CANS. The Private Practice, Academic Practice, and Large Group Practice Corners are excellent new additions bringing the full range of perspectives on issues important to CA neurosurgeons. The Resident’s Corner, Medical Student essays, and Women in Neurosurgery sections broaden readership interest in the CANS newsletter and provide new and differing perspectives on issues important to CA neurosurgeons. At the same time, California and national legislative and health policy issues important to CA neurosurgeons continue to be brought to our attention in a timely manner. Personally, I read the newsletter cover-to-cover as soon as it comes out each month. All-in-all I think you have expanded and improved an already excellent society newsletter. I wanted you to know that your hard work and efforts are noticed and certainly appreciated. Thank you for all you are doing.
Mark E. Linskey, MD, FAANS
Professor of Neurological Surgery
Department of Neurological Surgery
University of California Irvine
August 19, 2022
We were disappointed to read Moustapha AbouSamra’s editorial on “Changing Times” in the June 2022 issue of the CANS newsletter. He describes how physicians have lost control of Medicine to Hospital Administrators and the government, the decline in physicians’ reimbursement, while the hospital administrators’ salaries have increased significantly. He states that many physicians are employed by hospitals or large medical groups and laments that physicians have lost control of the patient. Any attempt to object by them will be met with the dismissal of the physician, labeled as “disruptive”, implying that their reputations would be damaged. He indicates that physicians can no longer determine the patients’ treatments, which are now controlled by insurance companies or governmental regulators. Moustapha states, “When we accept the care of a patient, we enter into a sacrosanct contractual relationship with the patient in which we are bound to choose the best course for that patient.” He says Doctors no longer have the power to provide care for the patient. What has happened to that unwritten contract to do everything possible to help the patient by the doctor? What Moustapha does not address is how did all of this happen … Moustapha offered no solution to his colleagues …
James I. Ausman, MD, PhD
Miguel A. Faria, MD
Editor’s note: Drs. Ausman and Faria’s letter is appreciated, and their criticism noted. They included in their response an essay 13 pages long with detailed references that I cannot publish here due to space limitations. However, this essay titled “American Medicine: Central Control and Corruption, The Patient Comes Last” will be Published in Surgical Neurology International in the next month or two. Here is the link: https://surgicalneurologyint.com/
Any CANS member who is looking for a new associate/partner/PA/NP or who is looking for a position (all California neurosurgery residents are CANS members and get this newsletter) is free to submit a 150 word summary of a position available or of one’s qualifications for a two month posting in this newsletter. Submit your text to the CANS office by E-mail (email@example.com) or fax (916-457-8202).
The assistance of Emily Schile and Dr. Javed Siddiqi in the preparation of this newsletter is acknowledged and appreciated.
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