1. New Work Comp Surgeon’s Fee Schedule
2. President’s Message
3. Report from Executive Secretary
4. Other News

1. Work Comp Fee Schedule, etc.

The California Division of Workers’ Compensation (DWC) says it will begin working in about two months on an update to the Official Medical Fee Schedule that would tie physician’s fees to Medicare’s Resource Based Relative Value System. This has long been anticipated and we have hung some black crepe on this in the past as RBRVS systems tend to downgrade surgeon’s fees. The acting Administrative Director (AD) of the DWC, Carrie Nevans, added a little kicker to the announcement when she indicated that “It is not necessarily going to be a zero-sum game,” which could be interpreted as possibly maintaining the present surgery fee schedule or at least dropping it less than a strict RBRVS system might require. Nevans clearly indicated that E&M payments should be increased but left some hope that fees for specialists may not have to be cut in order to boost payments to primary treating physicians. Since the last fee adjustment was an across the board 5% decrease in 2003, her statements could be construed as hope for a surgical fee increase but that is probably wishful thinking. It must be recalled that a real world RBRVS system is about relative work values or RVUs plus a monetary conversion factor. Nevans shouldn’t be able to manipulate the RVUs but she may be able to select different conversion factors for E&M and surgical codes which could bolster or hold surgical fees at the present level while boosting evaluation and management fees. Since this DWC project probably won’t start until early 2007, any new fee schedule may be more than a year away.

Nevans also has indicated the DWC has received 60 nominations of physicians for a committee that will evaluate medical treatment guidelines. CANS has submitted the names of two neurosurgeons for her to consider for the neurosurgical slot presumed to exist on this committee. We can only hope said committee will bring some present day light to the ACOEM treatment guidelines which are narrow, now dated and written with little surgical input.

Nevans has also said the DWC is revamping proposed regulations that will impose penalties for abuses of the utilization-review process. The new draft of the rules, to be released before the end of the month, will include a new version of the PR-2 form that physicians use to request treatment. Nevans said claims administrators must now often decipher lengthy and sometimes unclear narratives to find out what is being requested. The new form will have a box to check and a space to fill out the exact procedure being asked for. That may well help but it is my opinion it will take solid penalties to deter some insurance companies’ from employing UR hit men who engage in a selective and frequently irrelevant literature review so as to deny, by the gross amount of ink used, a pretty reasonably stated treatment request.

2. President’s message for October: Transitions in Neurosurgery

a. CMA House of Delegates
The California Medical Association House of Delegates (HOD) held its annual session in Sacramento from October 28 to October 30th, 2006 , where Don Prolo, MD and Pat Wade, MD represented CANS. Phil Lippe, MD represented the California Academy of Pain Medicine and I was Chairman of the Fresno-Madera delegation, but we all kept the representation of neurological surgery as a major concern.

There were many issues where most delegates had consensus, such as the balanced billing issue (proper reimbursement for services rendered), most managed care issues, but also many issues were marked by contentious debate and often rancor. The Proposition 86 discussion best illustrated the contentious issues.

CANS, as well as many other medical organizations too numerous to list here, but the Association of California Neurologists, California Association of Orthopedic Surgeons, Los Angeles County Medical Association, Monterey County Medical Association and Santa Clara County Medical Society are representative examples, oppose the passage of Proposition 86. We do not like tobacco or other unhealthy lifestyles, but buried in Prop. 86 are details that create a protection for hospitals for anti-trust. Prop. 86 states:

“to the extent that any hospital or hospitals work cooperatively in developing and implementing the plans for providing emergency services described in the section, the people intend that such hospital or hospitals shall incur no liability under federal anti-trust or other anti-competition laws prohibiting combinations in restraint of trade, including without limitation the provisions of Chapter 2.”

Prop. 86 does not provide physicians equal protection. In her October 3, 2006 Analysis of the Proposition 86 Anti-trust Exemption, CMA attorney Catherine Hanson stated: “Since the initiative provides an anti-trust immunity for hospitals but not for physicians, it creates a profound structural imbalance to the detriment of physicians.”

The CMA position, by means of a Board decision, supports Prop. 86, but it became clear at the House of Delegates that the CMA Board did not do its homework, and were unaware of the anti-trust implications at the time of their decision to support (a few Trustees did refuse to vote, concerned about lack of knowledge of the Proposition’s details). The CMA Administration and the majority of the Board have worked to avoid reversing the position that it had decided on, that of support of Prop. 86.

At the House of Delegates the debate was divisive and quite rancorous, but interestingly, since it was so divisive, the HOD finally voted to table the issue, not reversing the CMA position, but also refusing to confirm and support the Board position.

Hopefully, the electorate will vote the proposition down. If this does not occur, we physicians may well be encumbered in an unsatisfactory status, with much less leverage with the California Hospital Association. This would likely further aggravate the ER crisis, with physicians less likely to individually negotiate adequate ER coverage stipends. Also, there is no guarantee that physicians (or hospitals) will receive the funds (like the gas tax) and it will foster black market cigarette traffic, making Indian Casinos even more popular as sites to buy tobacco as well as buying on the Internet or going to other states, such as Nevada. There are other unsavory results, but these should be sufficient examples of the havoc that could occur should Prop. 86 pass. I would hope all on-call ER coverage and related physicians and their families would oppose Proposition 86.

Among the other controversial CMA House of Delegates issues, physician-assisted suicide (euthanasia) again played a large role. It is troubling to me that more resolutions sympathetic to physician-assisted suicide are occurring and there is some movement to tolerate it, but, fortunately, the House of Delegates voted that “CMA reaffirms its opposition to the legalization of physician-assisted suicide” (Resolution 520-06, substituted). Any modification of this view would be more than a slippery slope — it would be a greased pole. Other important issues occurred at the HOD, but this should serve as a sample of the business of the House of Medicine.

b. Kudos
Randy Smith should be congratulated for the award received at the recent CSNS and CNS meetings in Chicago . The award is the Leibrock Lifetime Achievement Award, given to recognize an individual who has dedicated himself or herself to the grass roots effort that is represented by the CSNS. We all should appreciate Randy’s talents and commitment to neurological surgery. Members like Randy are invaluable.

c. Annual Meeting
As I look forward to CANS Annual Meeting in January, I should note that CANS has an oral commitment from the new CMA CEO, Joe Dunn, Esq., to speak at the meeting. Mr. Dunn is a very successful attorney who represented Orange County as a State Senator in the California Legislature. Members will be notified once Mr. Dunn is confirmed as a speaker.

And a few words about the Meeting’s Banquet entertainment, Gary Ellison. Afflicted with polio as a child, Mr. Ellison’s physical activity was limited, but his intellectual ability was not as he focused his attention on learning to play the piano. He learned so well that he bears the title of official Ragtime pianist for the state of Missouri , a region known for jazz and ragtime music. Mr. Ellison has played at such venues as New York ’s Lincoln Center and Disneyland . Further, Mr. Ellison is a veteran USO performer, having entertained America ’s troops during the Vietnam and Korean Wars.

John Bonner, M.D.

3. Report from the Executive Office
a. Pain CME Reminder
December 31 is the deadline to comply with the state legislation for pain CME hours. California law (AB 487) requires physicians to complete 12 hours of continuing medical education (CME) in pain management. Doctors licensed in California after 2002 (when the law was enacted) have four years from the date of licensure to complete the CME requirement. If you are looking for a course, there is one scheduled by the CMA in Anaheim on December 1-2 or you can purchase a DVD to complete the requirement from home or office. Log on to www.calphys.org/html/cc237.asp for more information. The California Orthopaedic Association also has a class scheduled for December 9 in Los Angeles (contact COA at 916 454-9882).

b. Annual Meeting
Transitions in Neurosurgery: Capitalizing on the Sacramento Scene” — This is the theme chosen by Dr. Bonner for the CANS Annual Meeting on the weekend of January 12-14, 2007 at the Hyatt Regency Hotel. Meeting highlights include:

¨ Keynote Speaker Dan Walters, political journalist and columnist for the Sacramento Bee

¨ Senator Joe Dunn, new Chief Executive Office of CMA

¨ neurosurgical recruitment

¨ how and when to retire

¨ academic roundtable discussion

¨ electronic medical records

¨ accounts receivable

¨ NERVES (Neurosurgery Executives’ Resource Value & Education Society)

¨ lunchtime speakers on ER Negotiations

¨ risk management by NORCAL (attendance will qualify for a loss prevention discount)

¨ an entertaining evening in the Capitol View Room at the top of the Hyatt featuring ragtime pianist, Gary Ellison.

If you have not visited Sacramento lately, this would be an excellent opportunity to bring your families to see some beautiful and historic sites, such as the State Capitol, the newly restored Cathedral of the Blessed Sacrament, the famous Railroad Museum in Old Sacramento, the Governor’s Mansion, the Crocker Art Museum and many others. The tour of the State Capitol building should not be missed. Children, as well as adults, will find this a most fascinating tour. Most of these attractions are located within blocks of the Hyatt, making for a beautiful stroll through downtown and midtown’s tree-lined streets. Print complete schedule of events, registration and hotel information here.

c. Membership Brochure
CANS acknowledges the generous contribution by CAP-MPT for the printing and distribution of the CANS membership brochure which is in the process of being updated and will be sent to members within the next couple of months.

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

4. Prop. 86; Balance Billing; Personnel Changes; CSNS Actions in Chicago
a. Prop 86
This proposition, which uses the referendum process to gore the ox of a minority to fund the desires of a majority which doesn’t want to pay for said desires, will be law or not very shortly. If it passes, CANS should have some figures for you to use when it comes to the inevitable argument you will have with your hospital about how much to be paid to cover the ED and/or trauma service. Even if the proposition fails, these numbers should be helpful for you to use. The figures will be regional, includes ranges and certainly will not include figures from all hospitals that pay for coverage and will not be designed to determine what percentage of hospitals do provide stipends. Further, CANS does not discourage you from offering your coverage services as a community benefit at no charge at all—that is up to you. But if you think you should be paid, then our numbers will be a snapshot of the real world to be used in free market negotiations between you and your hospital.

b. Balance Billing Opinion
Two rather good letters about the balance billing issue to which we have referred previously were received by this editor and are attached to this E-mail for those that want to read the details. The first, written to Emilie Alvarez, regulations coordinator of the State’s Department of Managed Care and reproduced in part, is a somewhat lengthy but well thought out letter from Dana Launer, M.D., a San Diego surgeon. His discussion of the pitfalls of the dispute resolution process that had been proposed is worthwhile reading. The second letter was written by the CMA’s Jack Lewin to the Beaver Medical Group of Redlands, apparently a doc group with full risk contracts who one presumes had been favorable toward the proposed balance billing ban because of their experience with non-contracted docs billing exorbitant amounts for providing emergency services to their enrollees. His discussion of how the proposed regulation would harm medical groups like Beaver is well written. In previous newsletters (CANS newsletters of September and October of 2005 and archived on our Web site (cans1.org—newsletters), we have addressed what could be considered usual and customary charges for a doc to use when submitting a “reasonable” bill for non-contracted services. We understand that such charges are resisted by insurers and full risk groups and small claims court (a time consuming option with some limitations) may be needed to settle such disputes. It would benefit everyone if some reasonable regulations about dispute resolution could be created which include a level playing field for the neurosurgeon and the multi-billion dollar insurance company. I am not sure the California Department of Managed Care is the likely origin of a good solution. The CMA could help out here.

c. CMA & AANS Get New Leadership
Jack Lewin, M.D., left his post as CMA CEO to take over the American College of Cardiology and has been replaced. The CMA Board of Trustees appointed Joe Dunn, a state senator from Orange County , the new chief executive officer of CMA. Dunn is an attorney and was first elected to the state Senate in 1998. He was reelected in 2002. It is presumed he will leave elected office to run the CMA and will have some good Sacramento insight and contacts. Just how well he will meld with docs remains to be seen but senatorial cat herding experience may be a skill he can put to good use in dealing with CMA’s varied membership.

The AANS nominating committee has nominated Jim Bean, M.D., for the position of President-Elect. CANS had submitted his name and supported him for that position in no small part because of his strong CSNS background. He will be President when the AANS meets in San Diego in 2009. When I called to congratulate him, he asked that I express his appreciation for CANS’ support.

d. State Council Resolutions
At the Council of State Neurosurgical Societies recent meeting in Chicago , the six resolutions listed in last month’s newsletter received the following treatment:

Resolution I: That CSNS create working papers on new partner recruitment, practice compensation models and investing in ancillary service facilities. The CANS Board thought that NERVES (Neurosurgery Executives’ Resource Value and Education Society) would be a better group to pursue this but the CSNS decided to proceed with the documents written by CSNS committees and posted on the CSNS website (www.csnsonline.org).

Resolution II: That the AANS/CNS create online resources for medical students to peruse and learn about what it takes to become a neurosurgeon as well as providing a list of mentors for them to talk to. The CANS Board felt this info is already available and the CSNS agreed and chose to encourage the various training programs to keep their website information up to date.

Resolution III: That the CSNS request the Neurosurgery Board and the Residency Review Committee among other things reduce the length of neurosurgical residencies to one year of internship plus 4 years of residency. The CANS Board did not view this as an appropriate activity for the CSNS and the delegates agreed and defeated the resolution.

Resolution IV: That the CSNS be provided a page in each monthly edition of the two major neurosurgical journals to present the actions and accomplishments of the CSNS. The CANS Board agreed with this concept as did the CSNS delegates who referred it to committees for refinement.

Resolution V: That the CSNS establish and fund two summer fellowship programs for medical students to do neurosurgical socioeconomic research. The CANS Board questioned the ability of medical students to identify appropriate topics and thought the fellowships should also be offered to residents. The CSNS disagreed and adopted the medical student only plan as a 2-year pilot program costing $2500 per student.

Resolution VI: That the CSNS oppose economic profiling and credentialing of neurosurgeons. The CANS Board concurred as did the CSNS but the delegates felt some profiling was acceptable as long as based on quality measures as determined by organized neurosurgery and not on economic issues.

Of lesser importance, the CSNS gave its Leibrock Lifetime Achievement Award to the editor of this newsletter for service to the Council, CANS and the PAC over the years. Since my national activities sprang from CANS roots, the award should be shared in no small part with the California neurosurgeons who have supported my endeavors and in very large part with my wife Florence who has long been recognized as our partnership’s formidable framework to which I have merely added verbiage. I note that lifetime awards tend to be given to those who are nearer the end than the middle which is probably appropriate and personally worrisome.

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.