1. Medical Provider Networks—getting on them
2. New Comp Law—getting used to it
3. EMTALA TAG—getting defensive
4. CMA and MICRA—getting serious
5. Letter to the Editor—getting a view

1. Work Comp insurers use existing panels for MPN’s
It would appear that most Work Comp insurers have not had the time or inclination to create a real Medical Provider Network as required by present Comp law. Most of them have basically purchased physician PPO networks already in place. As an example, I am informed that SCIF has an arrangement with Blue Cross of California’s PPO to be their MPN that satisfies the law. Calling the BC PPO a Work Comp MPN stretches the imagination and in my mind certainly doesn’t meet the legislative goals of having a select stable of Comp savvy docs available for the benefit of the injured worker. Be that as it may, being a provider in any commercial PPO does not obligate any CANS member to see these patients and deal with their unique requirements and the rather substantial paperwork load they generate. For those of you who are interested in caring for these injured workers, you should contact all the PPOs in which you participate and request a WC addendum to your present PPO contract. You can expect said addendum to discount the Comp OMFS by 15% for the “privilege” of seeing these patients. If I were signing such an addendum, I would limit its duration to 1/1/06 because if the new OMFS due out then is some low multiple of Medicare RBRVS, you could, due to the 15% discount, be contracted to see these patients for Medicare rates or less.

Speaking of the new OMFS due 1/1/06 , our lobbyist is part of a coordinated effort to influence the Comp Administrative Director, Andrea Hoch, who will be promulgating the new fee schedule. Said AD Hoch is also on the short list for featured speaker at the next CANS meeting in San Diego in early 2006. That would at the very least be a very, very interesting encounter.

2. Supreme Court won’t toss new WC rules
The California Supreme Court refused to hear a lawsuit filed by the California Applicant’s Attorneys Association challenging the new Comp rules in effect since April 2004. This means we docs will have to continue to abide by the provision that requires us to determine impairment using the AMA guides. I continue to recommend purchase of the guides from the AMA by those who have to rate injured workers and taking a course on their use is still a good idea (we may have such an instructional course focusing on neurosurgical needs at the 2006 CANS meeting). The AMA has a number of related publications to help understand and use the guides but the one involving example case studies has little in it of use to those primarily rating spine and nervous system problems. The “Master the AMA Guides” is useful and the guide to range of motion assessment doesn’t add much to the instructions included in the AMA Guides itself.

3. Kusske takes testimony on EMTALA ED coverage
As previously discussed in this newsletter, our stalwart colleague John Kusske, chairman of the national EMTALA Technical Advisory Group on emergency coverage, has been conducting hearings on the issue of getting docs to cover the ED. He recently heard an excellent presentation by John Hill, a Ventura , California orthopedic surgeon whose testimony underscores our concerns about linking ED coverage to Medicare. His presentation can be viewed on the CANS Web site (cans1.org; click on members services then on EMTALA NEWS).

4. CMA Board increases dues for MICRA defense
At their May meeting, the CMA Board of Trustees voted to increase annual CMA dues in 2006 by $50 with the increase pledged solely for defense of MICRA in California . This line in the sand is another example of docs being asked to fund greater political action much as CANS did with its dues increase for 2005 when it pledged to employ a lobbyist to pursue its interests. The CANS dues increase of 100% from $250 to $500 was more substantial than the CMA increase, which is about 10%, but underscores doc activism. CANS so far has experienced about a 30% drop in membership in 2005 potentially due to the increased tariff (154 have paid dues; 69 haven’t) and it will be interesting to see if CMA members belly up to the political bar. CANS, with its very limited budget, can’t mount much of a MICRA defense so those of you who think it worthwhile to defend MICRA against an almost assured attack in 2006 can best help defend the line in the sand by being a CMA member and writing that membership check with commitment.

As a footnote, those 69 of you who have not paid your 2005 dues of $500 will shortly be receiving your 4th and last dues reminder. No response to that final reminder will result in membership termination. How can you stand to lose this brilliant newsletter?

5. Letter from Dr. Lederhaus

Dear Dr. Smith:
I reviewed the CANS newsletter. At least our approach (Dr. Lew
Disney, Dr. Jose Rodriguez and I) with respect to work comp has
been to stop doing work comp work. As you have probably seen, when we
request surgery work comp sends our reports to an outside reviewer who
does not feel surgery is warranted and thus delayed. This goes with
regular herniated discs with radiculopathy when all we are requesting is
a lumbar discectomy. We have had herniated synovial cysts as well
denied. In addition, chronic low back pain (even if the patient has
been on morphine, Oxycontin, etc.) for a long time they deny a lumbar
interbody fusion since the spine is not unstable (ACOEM guidelines
dictated against a fusion with a stable spine). It has become so
oppressive to deal with work comp that we stopped doing it all together.
In the rare case we will take, work comp has to agree that we are not
the primary treating doctor, that we will not determine the impairment
rating, will not do apportionment, and that the surgery has been
approved ahead of time. Only under those circumstances are we doing any
work comp. I don’t know if our response should be to fight for the
business or have all the neurosurgeons refuse to do the work. It is my
opinion that 10% above Medicare is not enough to deal with the reports
and following these patients for some times a year or more, only to come
back with a poor outcome since the patient can’t find a job.

With respect to outcome data, I think the only way we, as
neurosurgeons, could be powerful in that regard is if all the California
Neurosurgeons would fill out a database program filled with data that we
could use, compile and put out reports. This can be done with
Appleworks data base or File Maker Pro. I and my partners have
been using the Appleworks database for years to keep lists of our
consults and surgeries. This enables us to know how much of our business
is Medicare, Work comp, private, HMO, etc., and we can track payments as
well. If there were standard outcome measures, that could also be put
in. Otherwise, we will always be chasing our tails to compete with the
orthopods or each other.

Thanks for keeping us informed.
Best, Scott Lederhaus, M.D.

Thanks for the input, Scott.

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 Michael Edwards in the preparation of this newsletter is acknowledged and appreciated.