1. The Few, the Proud, the Members
2. What Are You Worth?
3. Annual Meeting Stuff
4. Do We Get What We Pay For?
5. Guidelines—Jekyll and Hyde

1. Membership increasingly selective
As we pass the equinox, further dues are not likely to be paid so the 55 active members and the 32 senior members who have chosen to spend their money elsewhere and will be dropped from our membership rolls which at this writing include 167 active members and 38 senior members who have stood up to be counted. I am surprised at the number of senior members delinquent since their $50 annual dues were not raised this year. Maybe we’re being too proactive for those like me who are approaching our dotage.

Speaking of senior members, Rick Batzdorf requested senior status but pointed out he will continue to do consultations and assist at surgery. This prompted a decision by the Board that the word “retiring” as used in the by-laws pertaining to qualifying for senior status will mean retirement from acting as primary surgeon if the member is 60 years of age or older but those younger have to cease all surgical activity to qualify.

Welcome to Alan Edelman as the lone new member voted in at the Board meeting.

2. Emergency care and the right to payment
Prompted by a call to Dr. Edwards by a CANS member, the Board decided to create and circulate an informational document about your rights to payment for caring for a patient under emergent or urgent conditions when you don’t have a contract with that patient’s insurer for a payment rate. California law (Health & Safety Code §1371.4) states that the insurer must pay you a reasonable fee for such care. The hooker of course is the definition of “reasonable.” The insurer would like that to mean what they pay their contracted physicians which is likely to hover around Medicare rates but you don’t have to accept that. Insisting on 5 times Medicare rates probably won’t fly but 200% of Medicare, which is the present Work Comp rate, seems a ballpark figure to use as a starting point. The California 2nd District Court of Appeals has recently confirmed your right to payment ( Bell vs. Blue Cross of California) and your right to go to court to get that fee. Depending on the amount, you might be able to use Small Claims Court and save a bundle on legal costs.

3. Annual Meeting program/speakers
The CANS Board of Directors confirmed two educational offerings for the January annual meeting in San Diego . Once again, there will be a 6 hour course on pain and end of life care which will satisfy one half of the credits you need to comply with the legislature’s imposition on us of 12 hours of such training by 12/31/2006 . I am told 85% of California physicians have yet to satisfy the 12 hour requirement. Our course will be reasonably priced, of good quality and hopefully tailored a bit to neurosurgeons who need to know a little about hospice and a lot about new pain drugs, drug combinations that really work (i.e., Gabapentin preop reduces postop pain) and the real skinny on pumps and stimulators.

Also, a 4 hour course on using the AMA Guides to determine impairment will be offered, definitely tailored and limited to the spine which is what most of us who do Work Comp need to know. Four hours should be adequate to inculcate competency even allowing how arcane the Range of Motion method to determine impairment is. Considering the cost of one and two day courses which teach more than we need to know, our course should be a steal.

There has been some reluctance on the part of the Administrative Director of the Department of Workers’ Compensation, Andrea Hoch, to accept our invitation to speak at the annual meeting. This is not surprising since once she publishes the rumored major reduction in Comp surgical fees in early January, our audience may not be constrained from venting their frustration at such a move. My view is that high profile political appointees should make themselves available to those they impact and not act like a Stealth bomber. The Board also voted to invite the Governor to address us—a long shot but who knows what forum he might choose to pursue his agenda and re-election.

4. Lobbyist a concern
Prior to engaging Mike Mattoch, we were advised that those that employ a lobbyist often have some difficulty in measuring the efficacy of such folks. This is understandable considering the somewhat ephemeral nature of the lobbying business but some concern was expressed at the Board meeting about communication or lack thereof between Mr. Mattoch and this writer and our executive secretary. Granted we are only paying him $2000/month and can’t expect hand holding for that amount, but not getting responses to specific queries or a monthly or even bi-monthly update (other than the routine press clips and weekly summary of Sacramento goings on that his firm E-mails to all his clients, 90% of which is not pertinent to CANS) has left us feeling ignored. The Board has initiated a formal request for some accounting of what has been done on our behalf. A good crisp presentation at the annual meeting on his dime wouldn’t hurt his credibility.

5. Board votes to not support treatment guidelines
One of the resolutions to be considered at the Council of State Neurosurgical Societies (CSNS) at their October meeting in Boston is one requesting that the AANS and CNS and their Joint Sections refrain from publishing treatment guidelines. That position is based upon concerns, among other reasons, regarding the lack of Class I data on most treatments and that guidelines offer more ammunition to the plaintiff’s bar to bring lawsuits for failure to provide appropriate care. The Board chose to support this resolution (CANS has 6 votes out of about 100) for the reasons stated in the resolution which were felt to outweigh the potential benefits of increased quality of care and reduction in unnecessary surgery.

For a recent example of such guidelines, the reader is referred to the June issue of the Journal of Neurosurgery:Spine wherein many recommendations based upon literature meta-analysis were made by an11 member panel of neurosurgeons and orthopaedic surgeons under the auspices of the Joint Section on Disorders of the Spine and Peripheral Nerves pertaining to lumbar fusion for degenerative disease. These guidelines recommend restricting the performance of one or two level fusions to a select population with limited use of pedicle screws (potentially saving many patients from undergoing a poor outcome procedure or the additional risk of screw placement—a laudable goal) while at the same time implying that a complete facetectomy done as part of a decompression for spinal stenosis without lithesis may well require a prophylactic fusion (something I never did in senior patients in 35 years of practice in one town with maybe 2 or 3 of them ultimately developing symptomatic lithesis requiring a fusion). The latter implication could expose me to a lawsuit for not fusing.

This is not a simple issue and one suspects that the AANS and CNS have thought this through and feel that benefits of guidelines outweigh the risks. It is to be noted that neurosurgeons on the above noted panel were all at universities and while that may well lend an air of legitimacy to the guidelines, they do come from those relatively well insulated from the misery of litigation that invariably casts the private practitioner as a bumbling dolt.

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.