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.” [https://revcycleintelligence.com/news/physician-practice-acquisitions-accelerated-during-covid-19 ; https://www.modernhealthcare.com/providers/nearly-70-us-physicians-now-employed-hospitals-or-corporations-report-finds ]. One source even estimates that number of doctors working outside of physician-owned practices may now even be as high as 70% https://www.beckersasc.com/asc-transactions-and-valuation-issues/70-of-physicians-are-now-employed-by-hospitals-or-corporations.html?origin=SpineE&utm_source=SpineE&utm_medium=email&utm_content=newsletter&oly_enc_id=5234C9729701J2Z

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 mlinskey@hs.uci.edu . 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 15^th 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 https://www.covid19.ca.gov 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 19^th 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 15^th 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 27^th and on June 9^th 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 https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=202120220AB615, As of the writing of this message it is not yet listed as having passed the State Senate to transition to the Governor https://openstates.org/ca/bills/20212022/AB615/ . 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 https://www.nytimes.com/2021/07/01/upshot/surprise-medical-bills-biden.html ; https://apnews.com/56b346bfa1ede219928b0968d2b5b374 . 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 https://www.medscape.com/viewarticle/955138?src=WNL_bom_210725_MSCPEDIT&uac=116516AG&impID=3527321&faf=1 . 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 22^nd, 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 https://www.modernhealthcare.com/providers/ama-seeks-overhaul-cdc-opioid-prescribing-guidelines . In addition, on July 19^th, the Department of HHS Secretary, renewed the Covid-19 Public Health Emergency (PHE) declaration for an additional 90 days beginning July 20^th . 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 mlinskey@hs.uci.edu. Even if you cannot dedicate your own time and effort, please consider financially supporting CANS, the national Neurosurgery Political Action Committee (Neurosurgery PAC) (https://www.aans.org/en/Advocacy/NeurosurgeryPAC), and the CMA Political Action Committee (CalPAC – https://www.cmadocs.org/calpac/donate ). Please do whatever you can to support CANS, the NeurosurgeryPAC and the CMA, they are fighting for you.

All the best!