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1. Your Position of Office Manager
2. President’s Message
3. Report from Executive Secretary
4. News Briefs

1. Harassment Risk
CANS members probably should know about AB 1825, a California statute requiring supervisors or managers of companies with 50 or more employees (full time, part time and temps) to receive 2 hours of training every 2 years regarding sexual harassment. Although there is no penalty for failure to accomplish this training, if a harassment case is brought and training has not occurred, the employer is in deep trouble. It is recognized that very few neurosurgical private practice groups will have 50 employees but some academic departments could reach that level. Lawyers who specialize in these cases recommend training for businesses with fewer than 50 employees as a way to bolster a defense if a case is brought. The newest training regulations allow online and self study as an acceptable alternative to the more common group sessions run by facilitators with specialized training in harassment issues. Perhaps the neurosurgeon in a two to six man group who is the group’s office supervisor might be a good candidate to get the training. At least one California neurosurgeon had his career aborted once the Medical Board of California got wind of his harassment case. The state agency to be contacted about the training is the Fair Employment and Housing Commission at (415) 557-2325.

Speaking of office managers, this is a fairly well compensated career path (134K to 210K/year) that a retiring neurosurgeon might want to consider as he/she disengages from being a doc and looks for an endeavor to maintain some cash flow and brain stimulation. The Medical Group Management Association (http://www.mgma.com/) would be a place to begin researching the options.

2. President’s message for August: Neurosurgery in Transition
Tobacco Tax (prop 86)
This has been a very busy time for neurological surgery, especially considering the possible impact of the Tobacco Tax (Prop. 86) and the Governor’s issued — and subsequently withdrawn — support for a balanced billing ban (although there is no guarantee that this is a permanent withdrawal).

The tobacco tax issue is an important one for neurological surgery. As a profession and a specialty, we are not in favor of tobacco use. But Prop. 86 includes more than just a tax on tobacco. Prop. 86 can be construed in such a fashion that it may interfere with neurosurgeons’ ability to negotiate appropriate and fair emergency room stipends. If Prop. 86 were to pass, it could put in place a system where a consultant would establish what is then-determined to be the stipend, and the consultant’s determination might then apply to all coverage groups across the board. This consultant’s stipend determination may be inferior to what may have been otherwise negotiated. This could aggravate our already present ER neurosurgical coverage crisis.

Further, Prop. 86 exempts hospitals from anti-trust action. This proposition states that hospitals working cooperatively in developing and implementing plans for emergency services will incur no liability under federal or state anti-trust or other anti-competition laws prohibiting combinations in restraint of trade. Hospitals would no longer be prohibited from collusive price fixing and other anti-consumer practices.

CMA has withdrawn its name from ballot support endorsement information, but the CMA Board still supports Prop. 86.

Balance Billing
The balance billing ban (rather a prohibition on proper and just billing by treating physicians) occurred after a Health Summit meeting mainly influenced by managed care entities, other insurance companies and consumers. At least temporarily, this ban has been rescinded, due to a great extent from CMA actions. We must persist in influencing the Governor and others in health care decision positions to allow proper additional billing by treating physicians. Unfortunately, as we all know, there are a few, even in our specialty, who over-bill, injuring our reputation and unjustly stressing patients. Fortunately, these latter physicians are a minority, but they do give ammunition to those who would like to compromise us.

House Officer Work Hours
The new house officer mandated work hour restrictions are still a great source of discussion and controversy. The 80 hour weekly limits went into effect on July 1, 2003 , so we have had an opportunity to evaluate the impact of the new rules.

There were many occasions as a house officer and in private practice when I could have benefited from such rules, but like many of us, never imagined that such a mandate would ever occur. Many of us remember when CT scans did not exist and our armamentarium consisted of a history and physical exam (especially a good neurological exam), still a very valuable approach, twist drill craniotomies, or bur holes, or percutaneous carotid angiograms. Fortunately, technology has advanced as has humanitarian considerations (house officer) although it has done so alongside increased medical personnel training and patient concern.

The number of articles regarding the house officer mandated work hour restrictions has been more numerous and extensive than I expected. The articles are varied in their evaluation of the impact of the weekly limits. The AANS has documented that residents now get less operative experience due to these restrictions. Another study showed that allowing scheduled naps increased better sleep patterns overall and decreased fatigue (not surprising – although I could imagine the response I would have received if I approached Art Ward, Jr., M.D. to ask for a nap!). There are still other studies that indicate that more coverage by others not that familiar with the patient (necessitated by the hours per week limit) enhance the likelihood of otherwise preventable adverse events. Weekly limits remain a controversial issue that can be revisited in more depth in the future

John Bonner, M.D.

3. Report from the Executive Office

Go to fullsize image Annual Meeting 2007
The result of last month’s membership survey (only 10 were returned) about topics for the Annual Meeting next January reflected some of the issues discussed at CANS’ recent Strategic Planning meeting. The January 12-14, 2007 Annual Meeting at the Hyatt Regency in Sacramento will include presentations on electronic medical records, recruitment of neurosurgeons, current legislative issues and risk management.

Dr. Bonner is planning an enjoyable weekend in Sacramento where there are a multitude of sites to visit for families and friends of meeting attendees. California ’s Gold Rush history can be explored in Old Sacramento, at the restored State Capitol or along the beautiful and lively waterfront. The Sacramento area is a vibrant and diverse destination offering an abundance of mental, cultural, culinary and physical activities. Since this is an election year, there will be new faces around the Capitol Building which is located directly across the street from the Hyatt. Whether you come for the history, the education, the politics, the recreation or the hospitality, there is always something to enjoy in the capital city.

You will be receiving registration material by mail the early part of October and information will soon be available on the CANS website (www.cans1.org).

WC Survey
The results of the survey compiled by the California Orthopaedic Association (COA) to determine if there were access problems in the Workers’ Comp system have been summarized by the COA and an extensive report has been prepared. This report focuses on the availability of medical treatment to injured workers throughout California following the 2004/2005 Work Comp reforms. It is intended to assess whether injured workers’ access to orthopaedic surgeons/neurosurgeons has been adversely impacted as a result of the reforms. 244 surveys were completed (231 surveys from orthopaedic surgeons and 14 surveys from neurosurgeons).

COA has concluded that the 2004/2005 Work Comp reforms have had an impact on the number of injured workers treated by orthopaedic surgeons and neurosurgeons. There is a statewide trend of orthopaedic surgeons and neurosurgeons reducing the number of injured workers they treat or dropping completely out of the system as they become frustrated with the utilization review system, reimbursement levels, or their inability to obtain authorization for medical services that they believe are medically necessary for their patients. If this trend continues, it is expected that access to quality care musculoskeletal care will continue to worsen, treatment will be delayed, temporary disability benefits will unnecessarily increase, and optimal recoveries will be jeopardized. There could be a resurgence of Workers’ Compensation “mills” if these problems are not corrected as the mainstream physicians will be driven out of the system.

COA will present results of this survey to the Division of Worker’s Compensation; contact the CANS office for a copy of the complete report.

Please contact janinetash@sbcglobal.net with your input on any of the above items.

4. The Governor Retreats; CMA Wiggles; Feds Pro and Con; Med-Mal Defense
Governor
After our lament last month about the Gov banning balance billing, it is noted that he has rescinded that edict at least for the time being. A great hue and cry did erupt led by the CMA and we would like to commend them and think our voice added to the din. A letter has been sent by CANS to the Gov pointing out the problems with such a ban and encouraging him to not resurrect the edict.

Tobacco Tax Initiative
The Tobacco-Tax initiative, which will be on the November ballot and which CANS voted to oppose as noted in the July newsletter, continues to be supported by the CMA. They have apparently removed their name from being listed on the supporter list on the ballot citing a sufficient amount of opposition among its members (CANS members among them) requiring the CMA to be more circumspect. Gutsy call! Since the CMA primary ED crowd plus the heart/cancer docs see potential greater support/reimbursement, the CMA will not oppose as we had suggested. You can bet if legislation was introduced that would limit ED/heart/cancer docs ability to negotiate a fair reimbursement rate, the CMA would rise up in righteous indignation but when the scene is only to limit the ED specialty coverage group’s ability to so negotiate fees for their coverage, then what is right drops behind what is politic. Is this principled leadership?

Spine Fusion Update
The following is excerpted from an AANS information item and is pertinent to those who do PLIF’s but feel that adding a postero-lateral fusion at the same time takes limited additional work, is associated with minimal additional risk and anesthesia time and may add to the likelihood of achieving a successful fusion at the operated level, but who were prevented from billing for the additional work by a CPT coding edit.

“On July 26, 2006 , the AANS and CNS were notified that the Centers for Medicare and Medicaid Services (CMS) would delete a coding edit that prohibits the reporting of CPT code 22612, arthrodesis, posterior or posterolateral technique single level; lumbar (with or without transverse technique) and CPT code 22630 arthrodesis, posterior interbody technique, including laminectomy and/or diskectomy to prepare interspace (other than for decompression), single interspace; lumbar together for the same lumbar level. The reversal will take effect on October 1, 2006 and came in response to a letter sent by AANS, CNS, North American Spine Society (NASS) and the American Academy of Orthopaedic Surgeons (AAOS) objecting to the edit. In the letter, the specialty societies made a strong case that the two arthrodesis procedures are distinct and separately identifiable, and as such, should remain separately reportable with the appropriate modifier, even when performed at the same lumbar level.

The deletion of the edit is retroactive to its implementation date of April 1, 2006 . Physicians who have had claims denied for CPT code 22630 because it has been reported with CPT code 22612 between April 1 and October 1, 2006 , may submit the claims for re-adjudication to their local Medicare carrier after October 1, 2006 .”

Spine Non-Fusion Update
The Feds have decided that the Charite artificial lumbar disc, the only artificial disc to be approved by the FDA (for one lumbar level), will not be covered for Medicare patients over 60 years of age. Apparently we sexagenarians and beyond are not worth the preservation of a motion segment. The Charite folks must be circling the wagons in light of the above plus the denial of coverage by Blue Shield (CANS newsletter October 2005) and what this writer noted while watching a mid-west television station recently. A law firm ad encouraged anyone who had a Charite disc implanted to contact the law firm, presumably to do something besides discuss the weather. This is déjà vu all over again if one recalls the pedicle screw thrash in the 1990’s. The only thing that seems to be missing is a 20-20 scare story about the Charite. Will the Charite folks have the moxie and/or money to stand up to the plaintiff’s bar on this issue much as Medtronic did in the pedicle screw attack? Stay tuned.

Med-Mal Defense
An article in Medical Economics is worth reading. It points out the potentially rough road you may have to travel to get top notch representation if you are sued. Like the space shuttle contractors, you may be represented by the lowest bidder. If the following link doesn’t work by clicking on the line while holding down the Ctrl button, cut and paste the line into the address line of your browser: http://www.memag.com/memag/article/articleDetail.jsp?id=361472 .

Randy Smith, M.D., Editor

The newsletter is a mix of fact, rumor and opinion. The facts are hopefully clearly stated. The rest is open to interpretation. The opinion is mine. R.S.

The assistance of Janine Tash and Jack Bonner in the preparation of this newsletter is acknowledged and appreciated.If you do not wish to receive this newsletter in the future, please E-mail or fax Janine Tash ( janinetash@sbcglobal.net, 916-457-8202) with the word “unsubscribe” in the subject line.