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1. New Workers’ Comp Fee Schedule2. President’s Message3. Report from Executive Secretary4. Other News

1. DWC Plans E&M Codes Increase—Surgery Fees Changes Coming Later

The Division of Workers’ Compensation (DWC) has dropped the first shoe and proposed increases for Evaluation and Management codes to take effect as of 2/15/2007 . The increases were felt to be necessary because present fees are less than Medicare rates (and they didn’t suffer the 5% decrease in 2004 because of that) and because the DWC feels the added burdens of dealing with the AMA Guides to impairment and the Utilization Review police justify more money for the 90201-90205 and 90211-90215 codes. The changes reflect about a 20% to 35% increase for the new patient evaluation codes and roughly a 20% increase for the established patient management codes except for the brief 90201 and 90211 codes which are pretty much unchanged. These increases will bring Comp E&M reimbursement up to a blended California Medicare rate. Although these changes are certainly welcome and overdue, the basic premise that Medicare rates are adequate compensation for dealing with the Comp patient is flawed. The ease with which one can submit a bill and get promptly paid by Medicare pales before the thrash involved with billing a Comp carrier and, after a billing review attempt at downgrading, finally getting paid in a month or two or three. The Comp patient report requires facility in the use of Comp syntax not necessary for Medicare patients and when the report involved does force one to use the AMA guides or the ACOEM guides or argue with a UR reviewer located in Ohio , then Medicare rates for the reports are woefully inadequate. The occupational medicine crowd, who makes a living using these codes, will see a nice and warranted pay increase. Those of us who do a specialist consultation and recommend involved treatment including surgery will still be underpaid. Hold your breath for the anticipated procedural fee schedule changes due out later in 2007 wherein decreases are anticipated. The second shoe dropping will likely be a clunker for neurosurgeons.

2. President’s Message for December
The year 2006 is almost history. When I was young, I never believed that time passed more quickly when one became older, as it is the same movement through space. But it is true that one’s perception of time does change, usually resulting in the impression of “time flying.”

a. Annual Meeting

The time left before our Annual Meeting ( January 12-14, 2007 ) is also growing shorter. I again urge the membership to attend what promises to be a diverse, productive and enjoyable series of sessions, varying from the serious (the scheduled topic presentations) to the entertaining (i.e., banquet with former USO ragtime piano player Gary Ellison). The soon-required transition to electronic medical records is an especially important topic, as well as neurosurgical recruitment, and the political scene – as presented by our keynote speaker Dan Walters – and, in addition, the CMA legislative update. There will be a risk management session with an opportunity for a Norcal loss prevention discount. On Sunday, there will be discussions on emergency room and trauma call issues, new techniques and equipment presentation (and other practice issues). Our own fairly recently retired Randy Smith will give his very informative and entertaining, although somewhat irreverent, retirement planning presentation. (I have had the privilege of previously hearing it). Overall it promises to be a well-balanced meeting.

b. CANS’ Activities

This has been a busy year, with a number of issues requiring board and membership attention. The recent election in which the so-called Tobacco Tax (Prop. 86) went down to defeat, with our activities opposing the proposition (hopefully aiding in its defeat), was a major issue. (You will recall that the anti-trust exemption protection for hospitals was our major concern with Prop. 86). Since the proposition was misleading, as its proponents targeted tobacco use, a lifestyle we also do not support, there was a lot of controversy with Prop. 86. I did get a number of calls from our membership about our activity opposing Prop. 86 – fortunately more in agreement with our position than against.

Other important issues included proper physician reimbursement for services rendered (the attempted ban on so-called balanced billing), the emergency care and emergency room crisis – more notable in some areas but present in most areas – and the subject of emergency room coverage stipends. Also, there was the Kuehl Bill (SB 840) attempting to establish a single-payer system in California , which, fortunately, was only a symbolic gesture by the legislature to an outgoing legislator. It received no fiscal consideration and it was well-known to be destined for the Governor’s veto. Workers’ Compensation was relatively quiet in 2006.

The Governor desires another health policy consideration in 2007, with plans for overhauling the $200 billion California health care industry. They say that all options are on the table in the “overhaul.” I believe that medicine, including CANS, should be at the table, to help influence the process in a physician-friendly fashion and serve as patient advocates (although we would not be obligated to support the product, if any, if we find it unsatisfactory). Nationally, we Americans spend approximately $2 trillion for health care, 16% of the GNP, which is increasing approximately 7% annually (in outlay, not GNP), so it is easy to understand the concerns of industry, government and consumers.

c. Thanks

I am indebted for all the good support, advice and help that I have received this year from the Board, Consultants and, especially, Randy Smith (CANS Newsletter editor) and Janine (in our Sacramento office). I wish to express a Happy New Year to all our members and families and hope that 2007 is better for us all. See you at the Annual Meeting in Sacramento ; be there.

John Bonner, M.D.

3. Report from the Executive Office

a. Annual Meeting

There is still time to register for the Annual Meeting coming up in about two weeks. There are still some rooms available at the hotel but you will need to call the Hyatt immediately (800 233-1234) to get the best rate. Registration forms can be downloaded from the CANS website (cans1.org).

b. Membership Update

The revised membership brochure (attached here) has also been added to the CANS website (cans1.org/membership/MembIntro.htm) as well as the membership application. Please encourage your colleagues to join.

c. Dues

Dues statements (reflecting the new decreased dues structure) will be mailed in mid-January. When you receive the dues request, be sure to carefully check the address information so that both the CANS database and the website will be as accurate as possible. This newsletter is sent by mail to those of you with no e-mail address on file. This will continue although we would prefer to send it electronically. You can include your e-mail address on the dues statement and indicate whether or not you wish to have any part of you contact information published. The newsletter can also be sent by fax upon request.

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

4. Acute Care Surgeon; Medicare Fees; Blue Cross Network Opt-Out; Annual Meeting

a. Acute Care Surgeon

We previously noted in our April 2006 newsletter (posted on our web site, cans1.org in the newsletter section) the controversial proposal by some prominent trauma surgeons to have a new class of trauma surgeon, the acute care surgeon, perform some neurosurgical procedures. The AANS and CNS have categorically opposed this although their opposition statements were a bit sparse. Now comes a very thorough and well documented opposition editorial by Alex Valadka, Shelly Timmons and Rich Ellenbogen published in the December 2006 issue of the Journal of the American College of Surgeons. The clearly written editorial brings some needed clarity to what has become a hazy debate based on some emotional and specialty survival issues. The complete text of the editorial is attached to this newsletter and is reprinted from the JACS, Vol 203, Valadka, et.al., ”Delivery of Emergency Neurosurgical Care,” Pages 962-66, Copyright 2006 with the kind permission of Dr. Valadka, the American College of Surgeons and their publisher, Elsevier.

b. Medicare Fee Freeze

By now you have surely heard that Congress killed the 5% Medicare fee decrease that was due to take effect in 2007. This is of course welcome news although we believe other Medicare regulation machinations will still reduce our surgical fees by about 3%. I find it sadly interesting that what we get paid to do a simple lumbar discectomy, just shown to be very effective in a recently published article in JAMA, is compensated in the $800 range by Medicare (and all the insurers who base their compensation rates on some fraction of Medicare payment) while at the same time insurers pour some real money into the fusion/metallic implant procedures whose outcome efficacy is much less well documented. We need to change carrots and triple payment for discectomy and reduce the compensation for lumbar fusions. That would be a more reasonable application of the total cost neutrality concept.

c. Blue Cross MPN Opt-Out

You do not have to participate in Blue Cross’s Workers’ Compensation Medical Provider Networks as part of your BC Prudent Buyer contract. You can imagine what BC will pay you in Prudent Buyer for caring for these patients with all their involved paperwork and rule comprehension. Neurosurgeons should be aware that even though Blue Cross has an “all products” clause in its Prudent Buyer contract, the plan agreed as part of its RICO settlement with CMA that it would not require physicians to participate in its workers’ compensation networks. Physicians who do not wish to participate in these networks can opt out by notifying Blue Cross in writing by January 21, 2007 . Even if you give such notice, you can’t actually get out of the MPN until January 2008. I love these settlements that give the poor insurers with their multi-billion dollar in a physician-friendly fashion and serve as patient advocates (although we would not be obligated to support the product, if any, if profits a full year of physician indentured servitude to ease the corporate shock of applying fairness. More details and the opt-out form can be found at www.calphys.org:80/html/cc286.asp. If you opt out, you are then free to negotiate an individual Comp contract with Blue Cross if you wish at what I would guess will be some fraction of the Official Comp Medical Fee Schedule (OMFS). Be alert here because although the Work Comp E&M payments are going up (see Item #1 above), the OMFS surgical codes will probably be paying less by 2008 and you need to calculate your floor for compensation.

d. Annual Meeting

At the risk of becoming a pest, I once again urge you to attend the annual meeting in Sacramento on Saturday January 13th and Sunday the 14th. The CANS Board has grappled with the annual meeting concept and decided that it affords an opportunity to hear from pertinent speakers, potentially hear from members regarding their concerns and allow some knowledge dissemination by nearby academic centers—all activities that can’t be accomplished well by this newsletter. Since information transfer is one of the two main functions of CANS (the other is to represent neurosurgeons at entities in California whose decisions impact our practice), an annual meeting, even if it doesn’t turn a profit, is a worthy endeavor. So please register for the meeting. If you can’t actually attend, your registration fee will be put to good use and I pledge to recount as best I can what transpires in Sacramento in our January newsletter.

Finally, 2006 is about to exit this never ending stage we populate. Can’t say it was a great year for CANS, medicine or mankind. Let us look forward to a 2007 with a hopeful heart. The best of the new year to you.

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.