Volume 49, Number 7

Inside This Issue

Picture of Mark Linskey, MD

Mark Linskey, MD

CANS President

President's Message

Over the last decade, there has been an inexorable fundamental paradigm shift in how physicians are employed in the United States. As private practice financial pressures and risks including rising medical liability costs, requirements to invest in expensive electronic health records, ever-growing regulatory compliance requirements, collide with an aging physician work force, there has been a dramatic shift from independent medical private practice to physician corporate employment. This shift is also present in academic medicine as University schools of medicine steadily shift to a health systems model dominated by the university medical center where academic departments no longer have financial autonomy and the faculty become salaried employees of an over-arching amalgamated academic health system. Neurosurgery was affected early. A AANS practice survey in 2012 showed that only 13% of US neurosurgeons were “hospital employed”. By 2014 this number had reached 53%, and has likely significantly increased since that time. Overall physician practice across the US is now catching up, with the Covid pandemic pressures providing additional impetus. On June 29, 2021 the AMA stated that, “for the first time, the majority of doctors worked outside of physician-owned practices as of last year.” [ ; ]. One source even estimates that number of doctors working outside of physician-owned practices may now even be as high as 70%

The definition of corporate employment is also somewhat shifty in light of the general statutory ban on the “Corporate Practice of Medicine” in the state of California. One quarter of patients in California subscribe to the Kaiser system, a corporate HMO. While Kaiser does not directly employ its physicians, they all belong to one of two large medical groups (Northern California Permanente and Southern California Permanente) which, although legally separate, are strategically, financially, and, to a large extent, politically integrated at the leadership and strategic planning levels with the overall Kaiser system. In academics, the days of financially and politically separate, quasi-autonomous, clinical departments who simply pay an annual “Dean’s Tax” to the medical school are long gone. Varying levels of “clinical integration” have led to the merger of school of medicine departmental finances under the overall school umbrella now often even merged the schools with their academic medical centers in a corporate health systems model. Most clinical departments no longer have separate financial reserves that can be accessed without corporate approval, and many now have academic faculty income determined by formulaic productivity equations for salary controlled at the institutional (corporate) level. At the private hospital level, the buying up of physician private practices is often performed through an “arms-length” “foundation model”, with the foundation in question largely controlled, strategically, financially, and politically, by the affiliated hospital system, with the physicians now employed by the foundation along a formulaic productivity salary equation. All three of these paradigms represent varying forms of corporate employment.

Corporate employment is here to stay and it presents California neurosurgeons with unique challenges, some of which are new and evolving, and many of which lie below the surface and are not clearly apparent until problems arise. It also presents professional organizations like CANS with new challenges as well. In order to remain relevant and useful in the service of our members, and thus neurosurgery patients, we must evolve and respond to this new paradigm with its new challenges. As a professional society we must research and investigate these new challenges in order to arm our members with the insight and tools necessary to protect the independent practice of neurosurgery, the health and wellbeing of California neurosurgical careers, and the optimal care of our patients. It is for this reason that the theme of our January 2022 CANS meeting is “Challenges of Corporate Employment”.

A preliminary gestalt would suggest that issues that might require exploration and deserve attention and presentation at our upcoming meeting might include, among others:

  • maintaining hospital Medical Staff (MS) independence from the Medical Center when the members of the MS are now de facto employees of the health system
  • the use of California Evidence Code Section 1157, originally designed to protect confidentiality of peer review from discovery, to shield unfairness, injustice and/or lack of due process in negative, selectively targeted, and/or hostile actions taken against physicians
  • difficulties in taking independent legal action to redress unjust actions taken under the screening protection of California Evidence Code Section 1157
  • sham peer review
  • selective and/or disproportionately targeted physician coding and re-imbursement, and/or HIPAA compliance audits
  • the misuse of the “disruptive physician” process and label to target physicians for issues other than abusive behavior or inter-personal anger management issues as the JCAHO originally intended
  • the evolution of MS Physician Wellbeing Committees into “Professionalism” Committees with overly broad and poorly defined purview, and their multi-year selective physician oversight/scrutiny contracts as a new means of physician control
  • the transformation of neurosurgery Department Chairs into corporate middle management positions, where their departmental vision, program building and recruitment plans increasingly require corporate scrutiny and approval, and where they are financially subsidized to communicate, carry out and enforce corporate policy(ies) among their faculty

These are just some preliminary ideas that our Annual Meeting Committee is considering for our upcoming meeting. I am sure that there are other important issues out there that we have not thought of. We also need to understand which issues should be considered priorities for initial focus since we do not have the time to address them all. We would really welcome input from all our members as we prepare, and eventually finalize, our annual meeting program. If any of you have thoughts or ideas please contact me by email ASAP. If any of you can share examples and precedents regarding any of the issues outlined above, we would love to hear them with confidentiality assured. If any of you have any ideas regarding neurosurgeons and/or other speakers that might be appropriate to address and present any of these ideas, we want to identify them ASAP. I can be reached at . Your thoughts, ideas, input and contributions would be most welcome! We must have our preliminary program fully organized and in place within the next 45-60 days in order to apply for CME approval.

Was it too good to be true? As outlined in our June 2021 CANS newsletter, on June 15th California suddenly “opened up” from Covid lock down restrictions. Only four weeks later, we began to experience what is now being called a “summer surge”, mostly fueled by the delta variant, which while much more transmissible than the original Covid virus, is much less virulent clinically. As of 7/23/21 according to 61.7% of CA eligible residents (children not yet eligible for the vaccine) are fully vaccinated, 70.9% partially vaccinated, and 39.1% still unvaccinated. The percentage of the latter that might have natural immunity from previously having Covid is unknown. However, we are now learning that even fully vaccinated people can get the delta variant (so called “breakthrough” cases), though symptoms for breakthrough cases appear to be even more mild clinically with few cases needing hospitalization. Currently 97% of cases needing hospitalization occur in unvaccinated patients, but the surge in positive cases is now large enough that on July 19th Los Angeles County re-imposed mask mandate for indoor public areas regardless of vaccination status. Indeed, the summer surge is now large enough that if the colored tiered system abolished June 15th was still in effect, then Los Angeles County would be back in the most restrictive purple tier and Orange County would be in the red tier. On 7/27 the CDC revised it’s guidelines to suggest that vaccinated persons should go back to wearing masks when indoors among large numbers of people (which would include professional meetings?). The CANS Annual Meeting Committee is monitoring the evolving situation very closely. While we still intend an in person annual meeting January 15-16, 2022, the new changes have impacted our venue choice final decision. We will ensure that the contract signed includes a “business as it was” plan with no restrictions as the hotel industry envisioned just four weeks ago, as well as a social distance and mask alternative space arrangement contingency plan just in case some level of restrictions return, as well as a no fault, no financial obligation, “force majeure” clause for contract relief if a new lock down returns prior to January 15, 2022. This has not been an easy negotiation.

In our April newsletter we alerted you to the California Assembly Bill AB 615, [Higher education Employer – employee relations act: procedures relating to employee termination or discipline] introduced February 12, 2021 by Assembly Member Rodriguez. The bill passed the State Assembly on May 27th and on June 9th was referred to both the Committee on Labor and Employment as well as the Committee on Public Employment and Retirement, by the state Senate. On 7/7/21 the bill was amended by the State Senate, As of the writing of this message it is not yet listed as having passed the State Senate to transition to the Governor . We will need to watch this bill closely as it will have potential significant effects on our California neurosurgery residency training programs.

Little of the healthcare news on the national front appears to be good news. On July 1, the Biden administration took its first steps Thursday toward finalizing the details of a ban on surprise medical bills that Congress passed and President Trump signed into law last winter. Without ever addressing the problem of artificially restricted “narrow networks” for physicians, out-of-network clinicians and service providers would be barred from billing patients for the difference between their charges and what insurance unilaterally decided to pay ; . Despite the efforts of our own AANS/CNS Washington Committee and other health care stakeholders, the Centers for Medicare & Medicaid Services (CMS) is moving forward with new prior authorization requirements for certain spine procedures performed in the hospital outpatient department. Effective July 1, neurosurgeons will need to seek prior authorization for cervical spinal fusion and implanted spinal neurostimulator procedures for Medicare fee-for-service patients. In a move that only 5% of physicians polled support, the American Academy of Physician Assistants (AAPA) recently voted to change the PA designation from “Physician Assistant” to Physician Associate”, which is apt to cause patient confusion and may be a first step in a move to try and follow Nurse Practitioners into independent practice . In a 7/19 email, we were notified that the AANS and the CNS have re-launched the Surgical Care Coalition campaign to prevent steep Medicare payment cuts in 2022. As of today, we are bracing for a 9% pay cut next year unless Congress acts.

On the hopeful side, on July 22nd, the AMA sent a letter to Center for Disease Control and Prevention, again urging the CDC to overhaul its 2016 opioid prescribing guidelines pointing out that the guidelines limit patients access to pain management treatments, potentially harm chronic pain patients, and harms physician’s practices focused on trying to help chronic pain patients . In addition, on July 19th, the Department of HHS Secretary, renewed the Covid-19 Public Health Emergency (PHE) declaration for an additional 90 days beginning July 20th . This means that all telehealth and other PHE waivers will stay in effect for at least another 90 days.

The CANS Board will be holding our next Board meeting Saturday August 7, 2021 from 0800 – end. The meeting must be early this year because the Council of State Neurosurgical Societies (CSNS) will be holding its Fall 2021 meeting prior to the special August AANS meeting in Orlando, Florida. The CSNS resolutions need to be considered by the CANS Board prior to the CSNS meeting. Please let me know ASAP if there are any topics or issues that CANS members wish to be brought up or considered at the 8/7/21 board meeting. I would be happy to add it to the agenda.

I would take this opportunity to ask all CANS members to please consider getting involved. We need your thoughts, ideas and input to help plan the best meeting possible January 2022. We are always in need of concerned, aware, and engaged neurosurgeons. Please do not hesitate to contact me regarding our upcoming meeting, and/or let me know if you would like to get more involved with CANS at Even if you cannot dedicate your own time and effort, please consider financially supporting CANS, the national Neurosurgery Political Action Committee (Neurosurgery PAC) (, and the CMA Political Action Committee (CalPAC – ). Please do whatever you can to support CANS, the NeurosurgeryPAC and the CMA, they are fighting for you.

All the best!

Picture of Randall W. Smith, MD

Randall W. Smith, MD

CANS Newsletter Editor

Medicare remains the 600 pound gorilla

According to Katie Orrico in the Neurosurgery Advocate:

Medicare is the largest single purchaser of health care in the U.S. Of the $3.2 trillion spent on personal health care in 2019, Medicare accounted for 23%, or $743 billion. 

  • By the numbers: Physician spending in Medicare accounted for 9% in 2019 (down from 13% in 2010) — totaling $73.5 billion.
  • Major proceduresonly account for 7.6% of physician spending, while evaluation and management services = a whopping 50% of physician spending.
  • Timely access to careis not a problem, and only 4% of Medicare beneficiaries report having to usually or always wait to see a physician for non-routine care resulting from an illness or injury.
  • Medical liability premiums are on the rise and account for a greater portion of the Medicare physician fee schedule than in previous years.
  • More beneficiaries are choosing Medicare Advantage(MA), with 26.4 million individuals enrolled in MA in 2021 (versus 4.6 million in 2003) — representing 46% of eligible Medicare beneficiaries.

According to data from the Medicare Trustees, Medicare physician pay has barely changed for nearly two decades, increasing just 7% from 2001 to 2020, or just 0.3% per year on average.

  • In contrast, Medicare hospital updates totaled nearly 60% between 2001 and 2020, with average annual increases of 2.5% per year for inpatient services and 2.4% per year for outpatient services.

Yes, but: The cost of running a medical practice increased 37% between 2001 and 2020, or 1.75 per year.

By the numbers: Nearly all neurosurgeons participate in Medicare; 99.1% in 2020 and 99.3% in 2021.

  • Overall, 98.9% of all physicians participate in Medicare — a fairly consistent rate across all specialties.
  • Specialties with the lowest participation rate are general practice (94.5%), addiction medicine (95.8%),  osteopathic manipulative medicine (95.9%) and psychiatry (96.9%) — still pretty healthy participation rates.

The bottom line: Fewer than 10,000 physicians do not participate in the program, demonstrating strong support for Medicare participation, despite concerns about reimbursement rates.

Picture of Moustapha Abou-Samra, MD

Moustapha Abou-Samra, MD

Associate Editor

Vaccines - What Do We Do Now?

California opened for business and lifted most of the COVID-19 related restrictions on June 15, 2021. From that point on, only unvaccinated people were expected to wear masks indoors. It was hoped that people will continue to receive the readily available vaccines, particularly since they have been proven safe and highly effective.

On July 20, my son Omar, visiting from Washington, DC, and I took my grandson Moustapha, eleven years old, and granddaughter Nour, eight years old, both visiting from Austin, TX, to our first Dodgers game since the pandemic. The kids wore their masks. It was a great game, though, unfortunately, our team lost in the last inning to our archrivals the Giants. It was a perfect Los Angeles evening at my favorite baseball stadium. We felt as if things were back to normal, and the pandemic is over. But were things back to normal? Surely, the pandemic is not over.

While at the stadium, we were expected to wear masks in all indoor spaces whether vaccinated or not. LA County had reinstated this mask wearing requirement the day before because of the alarming increase in COVID-19 infections and hospitalizations. This increase is due to two factors, the Delta variant that is highly contagious and … vaccine hesitance/resistance. A significant percentage of the eligible population in our country has so far refused to be vaccinated. In fact, Doctor Rochelle Wilensky, the director of the CDC indicated that this pandemic has become a pandemic of the unvaccinated.

It was hoped that by July 4, our Day of Independence, 70% of eligible people in the US would have been fully vaccinated, allowing us to celebrate our Independence from the pandemic. But we are nowhere close. The National percentage of fully vaccinated people is hovering around 50%. Vermont, a small state has 67.2% of its population fully vaccinated; California, the most populous state, is at 52.1%; Alabama has the lowest percentage at 33.9%. And there are huge discrepancies by counties. In Ventura County, CA, where we live, the fully vaccinated represent 55%, whereas in Burnet County, TX, where we had a second home the percentage is only 38%. Additionally, there is no uniform approach to this problem, not even in the same jurisdiction. For example, after LA County Health Department issued the mask mandate on July 19, the LA County Sheriff indicated that his deputies would not enforce it.

We are witnessing a significant increase of COVID-19 cases. This is everywhere, but particularly in the states with the lowest vaccination rate. 83% of cases are now of the Delta variant and younger adults seem to be the ones most affected. Clearly, those who are not vaccinated are responsible for perpetuating this pandemic.

Peoples’ reasons not to get vaccinated vary. I am afraid a large number are taking a political stand, which is unfortunate. Some blame the fact that the FDA has not formally approved the vaccine; some feel that the government has no role in forcing citizens to get vaccinated; and some are simply ignorant and believe in conspiracy theories; they are fearful that the government is adding a microchip to every vaccine, thus allowing it to keep track of each of us.

There have been anti vaxxers since Jenner discovered the smallpox vaccine. This is not new; though the politicization is a new and distressing phenomenon causing significant increase in the number of vaccines rejectors. Some of the anti vaxxers’ excuses/justifications are:

  • Vaccines may contain unsafe toxins
  • Vaccines can cause autism
  • Vaccines can weaken children’s natural immune system
  • Why use vaccines against diseases like measles and polio since their prevalence is so low
  • Natural immunity is better and is superior to immunity gained from vaccines.

Of course, none of this is accurate and the link between vaccination and autism has been thoroughly debunked.

We have 10 grandchildren. The oldest is eleven. So, none of them qualify to receive the vaccine, yet. We are hoping that the day will come soon when a safe and effective COVID-19 vaccine for children is developed. I am optimistic since the mRNA vaccine technology has proven to be simply amazing.

What will happen when our children/grandchildren go back to school? They will be exposed to other unvaccinated children from families who may not be vaccinated. They will potentially get infected or bring COVID-19 in one of its present or future forms to us and we stand a chance to get infected. We do know that even vaccinated people can get infected. We also know that vaccinated people can harbor an asymptomatic form of COVID-19 and then pass it on to unvaccinated people.

What can be done to make people get the vaccine?

Ross Douthat, a New York Times columnist suggested paying people to get the shot. If they get both shots, they can receive $1000. This may not be fair to the rest of us who received the vaccine because it was the right thing to do, but it may stop the present surge. However, I don’t think this is the best idea.

I think the solution is to mandate COVID-19 vaccination. This is not a personal choice, rather it is a public health issue in the midst of a devastating pandemic that claimed the life of 626,762 of our neighbors and fellow citizens, as of this writing. And I don’t think that waiting for a formal FDA approval of the vaccine/vaccines makes sense.

The irony is, while most of the world is trying to find enough vaccines for their ravaged population, here in the US we are at risk of having vaccines expire while on shelves waiting to find arms of individuals who are willing to get the shot.

Meanwhile, I think everyone should wear a mask when indoors in public places. I do. About half the people we encounter in such places are not vaccinated.

Tidbit #1 - The Gorilla Continues the Specialty Takeaway

On July 13, the Centers for Medicare & Medicaid Services (CMS) released the proposed 2022 Medicare Physician Fee Schedule. Overall, neurosurgery will receive a 3.2% payment cut in 2022. The cut stems from a lower conversion factor — which goes from $34.89 in 2021 to $33.58 in 2022.

  • The 3.75% payment increase was provided for by the Consolidated Appropriations Act…but only for one year.
  • Remember…additional cuts — 2% due to Medicare sequestration and 4% due to Congressional pay-go rules — will happen in 2022 unless Congress acts this year.

Yes, but: That’s not all. CMS rejected the RVS Update Committee (RUC) recommended work relative values (wRVUs) for the new laser interstitial thermal therapy (LITT) codes and the new arthrodesis decompression add-on codes (to report decompression when performed in conjunction with posterior interbody arthrodesis at the same interspace).

  • By the numbers: wRVUs for LITT code 617X1 went from 20.00 to 19.06 and from 24.00 to 22.67 for code 617X2; wRVUs for 616X1 went from 4.44 to 2.31 and from 5.55 to 3.08 for code 616XX.
  • Fortunately, CMS agreedwith the RUC-recommended increase for code 22867 (insertion of interlaminar/interspinous device), increasing the wRVUs from 13.50 to 15.00.
  • Unfortunately,CMS once again failed to incorporate the increased evaluation and management (E/M) values into the E/M portion of the global surgery codes — perpetuating the devaluation of surgical services.

Tidbit #2 - CAP with another pearl

The Cooperative of American Physicians (CAP) created One Step Ahead: An Essential Guide for Running a Successful Independent Medical Practice to help you stay ahead of issues stemming from pandemic-related challenges, regulatory changes, and more.

Download Now


Human Resources Compliance in the Age of COVID-19In this guide, you will find a comprehensive collection of articles and resources addressing the following:

  • The Patient Experience and Your Bottom Line
  • Managing the Billing Office
  • Consent and Privacy in a Virtual World
  • Standards for Proper Documentation
  • And much more!

As a leading provider of superior medical malpractice coverage in California for more than 40 years, CAP is pleased to offer this free resource to help you and your staff run a safe and successful practice.

The Observation for the Month

By the time of the CANS Annual meeting next January, it is anticipated that kids can be vaccinated, booster vaccine shots will be common, and the ranks of the unvaccinated will be thinned due to the deaths that group will experience.


AANS: Annual Meeting, August 21-25, 2021, Orlando, FL

CSNS Meeting, August 20-21, 2021, Orlando, FL

NERVES Annual Meeting, August 18-20, 2021, Orlando, FL

Western Neurosurgical Society: Annual Meeting, Santa Ana Pueblo, NM, September 10-13, 2021

North American Spine Society: Annual Meeting, September 29-Oct. 2, 2021, Boston, MA

Congress of Neurological Surgeons: Annual Meeting, October 16–20, 2021 Austin, TX
CSNS Meeting, October 15-16, 2021, Austin, TX

International Society for Pediatric Neurosurgery: Annual Meeting, November 14-18, 2021, Singapore

AANS/CNS Joint Pediatric NS Section: Ann. Meeting, December 7-10, 2021, Salt Lake City, UT

Cervical Spine Research Society: Annual Meeting, December 2-4, 2021, Atlanta, GA

CANS, Annual Meeting, January 15-16, 2022; Location TBA

Southern Neurosurgical Society: Annual Meeting, February 17-19, 2022, Hollywood, FL

California Neurology Society: Meeting, November 12-15, 2021, Santa Barbara, CA

AANS/CNS Joint Section on Pain: Annual Meeting, TBA

Neurosurgical Society of America: Annual Meeting, 2022 TBA

Rocky Mountain Neurosurgical Society: Ann. Meet., 2022, TBA

New England Neurosurgical Society: Annual Meeting, 2022, TBA

AANS/CNS Joint Cerebrovascular Section: Annual Meeting, 2022, TBA

AANS/CNS Joint Spine Section: Annual Meeting, February 23-26, 2022, Las Vegas, NV

North American Neuromodulation Society: Annual Meeting, 2022, TBA


Looking for a new partner or position?

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 (

To place a newsletter ad, contact the executive office for complete price list and details.


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