1. Lobbying: next chapter
2. Artificial Disc
3. Annual Meeting Info
4. Guidelines: next chapter
5. Follow Ups
6. ED Coverage

1. News from the Lobbyist Front
In response to a letter sent by President Edwards expressing our concern about lobbyist Mike Mattoch’s lack of communication with us, Norwood Associates responded with a 3 page letter from Mr. Norwood. The absence of Mr. Mattoch’s name in the corporate title was confirmed by Mr. Norwood as he indicated Mr. Mattoch resigned from the firm in late September to pursue other opportunities. He noted that Mr. Mattoch had been called to active duty in July and August, hampering his effectiveness, and that the last few weeks of the legislative session are very busy which also interferes with individual client communications.

He provided an update on legislation in which we had an interest plus the lobbying effort to influence the new Official Medical Fee Schedule (OMFS) for Work Comp, the latter apparently failing to alter then Administrative Director Andrea Hoch’s plan to impose some type of RBRVS system almost sure to significantly reduce physician’s fees (SCORE: CANS 0; other interests 1). He noted that our interests were represented in creation and support for the Vargas bill (AB 681) that would have frozen the OMFS at present levels for 3 years and that the bill was placed in legislative purgatory until the next legislative session (SCORE: CANS 0; other interests 2). He also felt that the defeat of the Speier bill (SB 292) that would have established a reimbursement rate for repackaged drugs sold out of physician’s offices was due to lobbying activities on behalf of CANS and the CMA. I wasn’t aware we were opposed to this bill since reselling drugs in the office, particularly to Work Comp patients, is more of an Occ-Med and orthopaedic activity and not one of great concern to neurosurgeons—but we can give the benefit of the doubt here (SCORE: CANS 1; other interests 2).

He further noted that the Chan bill (AB 757) that would have tended to thwart silent PPOs, which we did support, was put in a suspense file for maybe resurrection next year (SCORE: CANS 1; other interests 3). He didn’t mention the Yee bill (AB 516), that CANS opposed and that would have prohibited docs who have an imaging machine in the office from using it on their patients. The bill was withdrawn by the author but apparently not due to any lobbying effort on our behalf.

Mr. Norwood’s letter to Dr. Edwards reflects some responsiveness to our concerns, includes an offer to meet with us for further discussions and an interest in continuing to represent CANS. The CANS Board of Directors now needs to mull this communiqué over. Maybe we should tell Mr. Norwood we plan to terminate our agreement (keying the 60 day out clause of our contract with him) pending a presentation at the Board meeting in January.

2. Non to Charité
Blue Shield of California holds a periodic meeting to consider whether or not to cover newer technologies and treatments. At such a gathering, they invite various organizations, including CANS, to express views. Thus it was that CANS board member Mike Robbins attended the most recent Blue Shield meeting at which the Charite artificial disc was up for coverage consideration. Bias must abound at such gatherings; bias by Blue Shield to limit coverage and keep the bottom line robust and bias by the presenters with their individual or specialty group slant on what’s good for Mr. and Mrs. California . Some argued, consistent with the CANS position, that the Charite has satisfied the FDA when used under strict guidelines and that the European experience now approaching 10 years would support their use. Among those speaking against adoption was Dr. Charles Wilson, former neurosurgery chief at UCSF, CANS board member and Pevehouse Award winner, who I believe has limited his professional activities to health plan administration for the past 10 years. One might predict the outcome here with work-a-day surgeons trying to take care of axial back pain patients hoping to have an option to AANS/CNS blessed fusion opposite Dr. Wilson with his impeccable CV and MBA. The Charite was voted down. Maybe we shouldn’t be too critical about this since when Moose Abou-Samra, another CANS board member, recently took the Charite installation course, he was informed that a very considerable number of the discs sold were for multiple levels in the same patient, an off-label approach to say the least. On the other hand, not approving their use for single level disease which the FDA approved seems potentially short sighted. I suspect the Blue Shield decision delighted the pedicle screw companies.

3. Annual Meeting: Exhibitors and Overview
The companies listed below supported CANS by exhibiting their wares at last year’s meeting with their exhibitor fees helping to deliver a positive bottom line for the meeting. They will of course be contacted again and it would help if CANS members mentioned to their local reps that we hope to have them on board again this year in January. Further, if you have a good relationship with a rep from a company not on the list, a little hint about joining us in San Diego would be useful. Have them contact Janine Tash, our executive secretary, at 916-457-2267 or janinetash@sbcglobal.net .
Aesculap, DePuy Spine, Guilford, Integra, Kyphon, Medical Designs, Medtronic, NeoSpine
Radionics, Synthes Spine, Stryker Spine,TrueMRI, Ortho Development, Lippincott Books
You will soon be receiving registration material for the 34th CANS Annual Meeting the weekend of January 13-15, 2006 at the Sheraton Suites downtown San Diego located near the historic Gaslamp Quarter.

Saturday morning’s socio-economic session will feature timely updates on the emergency room crisis, EMTALA, CANS’ lobbying efforts, Workers’ Compensation and malpractice issues. In the afternoon, there will be a 4-hour QME course on the use of the AMA Guides to Impairment Ratings for Spine.

Sunday will feature the last in a series of Pain Management course where you can obtain 6 CME hours which is half of the California requirement of 12 hours required by law by the end of 2006.

Saturday’s banquet will be held in the University Club in the Symphony Towers located on the 34th floor of the Symphony Towers building in downtown San Diego . This site offers the most spectacular views in all of San Diego . Please register early and help make this annual event a successful one.

4. Concern about Guidelines kicked upstairs
I am informed the debate on the CSNS Resolution encouraging the AANS/CNS to not publish guidelines because of the perceived lawsuit risk if one does not adhere to such guidelines, a position supported by the CANS Board, was hot and heavy at the recent CSNS meeting in Boston . Those who felt guidelines provide reasonably documented best practices which, if followed, should result in better outcomes while limiting patient risk were countered by those who felt that guidelines published on less than Class I data suffer from the dual sins of loose consensus and author bias. Pro-guideliners countered with the position that waiting for Class I data deprives patients of good practices likely to benefit them and that if we have to limit guidelines to Class I data, we will never be able to bless very good stuff, such as parachutes. In the end the resolution was amended to wit: BE IT RESOLVED, that the CSNS requests the AANS and CNS refer the issues raised at the Boston 2005 CSNS plenary session regarding the potential medical legal implications of guidelines development and production to the Quality Improvement Workgroup of the Washington Committee for adjudication and report back to CSNS.

5. Follow-ups

Work Comp change of guard: As noted in last month’s newsletter, Andrea Hoch, then Work Comp Administrative Director, was to be invited to speak at our annual meeting. Since then, she has been kicked upstairs (?downstairs, ?outside) to become the Governor’s legal advisor. Carrie Nevans, a Hoch lieutenant at the DWC, has been named acting director. As a former State Compensation Insurance Fund adjuster, Nevans may bring a very good working insight to her new post. The question might be asked, in light of her SCIF experience, does she have a jaundiced view of providers requesting authorization for such things as manipulation under anesthesia or 3 level fusions for spine pain or will she be guided by a concern for injured workers and the mostly reasonable docs who treat them? This is a definite stay tuned.

ED compensation: After last month’s comments about what you should get paid for providing emergency care to a patient with commercial insurance from a company with which you have no contract, a CANS member from the San Jose area, wrote that “the CMA says that our usual and customary fee, which we should be able to document as discounted to within the 80th percentile range in the Medicode book, is the legally acceptable rate for emergency room reimbursement.” The Medicode book to which he refers lists area fees at various percentiles. As an example, CPT code 61304, exploratory craniotomy, for which Medicare allows about $1500 is listed at about $4700 (80th percentile) in the Medicode book for San Jose . The 50th percentile is at about Work Comp rates. That should be real ammunition in a fight with an insurance company. The Medicode book for your area can be obtained by calling 800-765-6588 (ingenix.com).

6. Collective Bargaining
CANS members are about to receive a survey form to express interest in pursuing a collective bargaining agreement for ED coverage with the state of California . Such an agreement, which is not easy to accomplish and is expensive to float through state bureaucratic process, would allow neurosurgeons to collectively bargain with hospitals for ED coverage with the state monitoring and overseeing the process. This exemption from Taft-Hartley is allowed if the needs of its citizens override the monopoly issue. There are those, exemplified by Don Prolo in San Jose , who feel this approach would significantly improve ED coverage and compensation. Others, like Mike Edwards at Stanford, feel that most often the problem is not the compensation issue but a life style issue and no amount of compensation will attract neurosurgeons back to the ED from their elective spine practices. It would be very helpful if CANS members fill out this survey so as to guide time and monetary commitment by our organization.

Randy Smith, M.D.

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.