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AANS
NEUROSURGEON
Information and Analysis for Contemporary Neurosurgical Practice • Volume 18 No. 2
This is not healthcare reform
What Do Neurosurgeons
Need to Know About
Healthcare Reform?
INSIDE: THIS AANS PRESIDENT WANTS YOU TO SEND A MESSAGE TO CONGRESS, 28 • PRACTICING NEUROSURGERY IN CANADA, 42
VOLUME 18, NUMBER 2
Contents
Special Feature
42 A Global Experience: Practicing
Neurosurgery in Canada
J. Max Findlay, MD
44 Considering Cracks in the Canadian
Healthcare System
James T. Rutka, MD
PEER-REVIEWED
RESEARCH
46 Efficacy and Limitations in
Providing Online Information for
Neurosurgical Residency Applicants:
A Review of Nsmatch.com
Nicholas Szerlip, MD, Mark Iguchi, MD, and
Jay Jagannathan, MD
INSIDE
NEUROSURGEON
27 The Inside Neurosurgeon section of the AANS
Neurosurgeon focuses on the news and views of
Features the AANS and other neurosurgical organizations.
Selected contents are listed below.
Cover Focus 28 AANS President’s Perspective
5 This Is Not Healthcare Reform Troy Tippett, MD, wants you to send a message
to Congress.
While there is widespread acknowledgement
that the U.S. healthcare system is not economi- 30 AANS Annual Meeting
cally viable for much longer without some sort The 77th AANS Annual Meeting showed how
of change, there remains little consensus on scientific inquiry through a global prism helps shape
what healthcare reform should entail. neurosurgery’s future.
6 Healthcare Reform: What Neurosur- 34 AANS Governance
geons Need to Know AANS leadership for 2009–2010 takes office.
Katie O. Orrico, JD 36 Washington Watch
14 Medical Liability Reform: A Critical Neurosurgery seeks to influence healthcare reform
Component of Patient Access to Care via the 2009 AANS/CNS legislative agenda.
James R. Bean, MD, tells Congress why medical
liability reform is essential.
38 Advancing Neuroresearch
The 2009 research and medical student fellows are
15 AANS on Capitol Hill: A Personal announced.
Perspective
Michael Schulder, MD 40 Calendar/Courses
The AANS/CNS Pediatric Section meets
17 NeuroPoint Alliance: Single Portal Dec. 1–4 in Boston.
Helps Neurosurgeons Navigate Quality
Reporting and Data Collection Initiatives
Manda J. Seaver
20 Toward Viable Universal Health
Insurance: Massachusetts, California
Test Reform
Patrick W. McCormick, MD
Vol. 18, No. 2 • 2009 • WWW.AANSNEUROSURGEOn.ORG 1
C on t en t s
30 22 56
DEPARTMENTS 22 FaceTime 54 Letters
Economist Uwe Reinhardt offers his perspec- A reader says general training
41 Bookshelf tive on healthcare reform. maximizes career flexibility for physician
“Better” is an argument for quality assistants.
improvement. 3 Frontlines
Gary VanderArk, MD The proposed 2010 Medicare fee schedule 56 Timeline
may mean net gains for neurosurgery. If you’re tired of hearing about health
26 Education services in the U.K. and Canada,
The CAHPS patient survey will satisfy one 24 Gray Matters consider Turkey.
of the new Maintenance of Certification How would you treat parafalcine subdural Michael Schulder, MD
requirements. empyema? Results of the previous survey and
William T. Couldwell, MD related commentary are reported on page 25.
Jacob Alant, MD, and Rajiv Midha, MD
Michael A. Sheinberg, MD letters
Allen K. Sills, MD Send your comments on articles you’ve read in
Shelly D. Timmons, MD these pages or on a topic related to the practice
Alex B. Valadka, MD of neurosurgery to aansneurosurgeon@aans.org.
Monica C. Wehby, MD Include your full name, city and state, as well as
disclosure of any conflicts of interest that might
Peer-Reviewed Research have bearing on the letter’s content. Correspon-
AANS MISSION AANS Neurosurgeon seeks submissions of dence selected for publication may be edited for
The American Association of Neurological Surgeons rigorously researched, hypothesis-driven articles length, style and clarity. Authorization to publish
(AANS) is the organization that speaks for all of neu- concerning socioeconomic topics related to neurosur- the correspondence in AANS Neurosurgeon is
rosurgery. The AANS is dedicated to advancing the gery. Selected articles are reviewed by peer-review assumed unless otherwise specified.
specialty of neurological surgery in order to promote panelists. Papers must comport with the appropriate
the highest quality of patient care. instructions for authors. AANS NEUROSURGEON Online
Peer-Review Panel led by Deborah L. Benzil, MD The advanced search of AANS Neurosurgeon and
AANS NEUROSURGEON
William E. Bingaman Jr., MD; Frederick A. Boop, AANS Bulletin archives since 1995, subscription
The official socioeconomic publication of MD; Fernando G. Diaz, MD; Domenic Esposito, to the RSS feed and table of contents alert, and
the AANS, AANS Neurosurgeon (formerly AANS MD; David F. Jimenez, MD; Mark E. Linskey, MD; more are available at www.aansneurosurgeon.org.
Bulletin) features information and analysis for Mick Perez-Cruet, MD; Richard N. Wohns, MD
contemporary neurosurgical practice. PUBLICATION INFORMATION
William T. Couldwell, MD, editor WritE FOR AANS NEUROSURGEON AANS Neurosurgeon®, ISSN 1934-645X,
is published four times a year by the AANS,
Patrick W. McCormick, MD, co-associate editor www.aansneurosurgeon.org
5550 Meadowbrook Drive, Rolling Meadows,
Michael Schulder, MD, co-associate editor Ill., 60008, and distributed without charge to the
OPEN, ONLINE ARTICLE submissions neurosurgical community. Unless specifically
Manda J. Seaver, staff editor Nonpromotional articles that are in accordance stated otherwise, the opinions expressed and state-
with the appropriate instructions for authors, ments made in this publication are the authors’ and
EDITORIAL BOARD
are original, and have not been published previ- do not imply endorsement by the AANS.
Deborah L. Benzil, MD ously may be considered for publication. A link to
William E. Bingaman, MD the article submission portal and to instructions © 2009 by the American Association of Neuro-
Rick A. Boop, MD for all types of submissions is available at www. logical Surgeons, a 501(c)(6) organization, all
Lawrence S. Chin, MD aansneurosurgeon.org.The AANS reserves the rights reserved. Contents may not be reproduced,
R. Webster Crowley, MD right to edit articles for compliance with publica- stored in a retrieval system, or transmitted in any
Eric M. Deshaies, MD tion standards and available space and to publish form by any means without prior written permis-
Joseph A. Hlavin, PA-C them in the vehicle it deems most appropriate. sion of the publisher.
Rajiv Midha, MD Articles accepted for publication become the
Gregory J. Przybylski, MD property of the AANS unless another written ADVERTISING SALES
Gail L. Rosseau, MD arrangement has been agreed upon between the Greg Pessagno, Walchli Tauber Group, (443) 512-
Mitesh V. Shah, MD author(s) and the AANS. 8899, ext. 109, or greg.pessagno@wt-group.com
2 Vol. 18, No. 2 • 2009 • AANS NEUROSURGEOn
FRONTLINES
NEWS TRENDS LEGISLATION
In the Loupe This susceptibility-weighted image in a 58-year-old woman with familial cerebral
cavernous malformations demonstrates dozens of lesions. Previous MRIs with
conventional sequences had revealed only the four largest cavernomas. Contributed
by R. Webster Crowley, MD, Charlottesville, Va., and Arnold Bok, Auckland, New
Zealand. They reported no conflicts for disclosure.
Proposed 2010 Medicare Fee Schedule
May Mean Net Gains for Neurosurgery
Early analysis of the proposed regulation for the Reporting Initiative incentive payments of 2 percent
2010 Medicare physician fee schedule, which was of estimated allowed charges for those who report
published in the Federal Register on July 13, indi- data on PQRI quality measures through claims,
cates a 2 percent overall gain for neurosurgery. This to a qualified registry, or through a qualified EHR
estimation excludes possible changes in the sustain- product; and 2 percent bonuses to participants in
able growth rate formula—such as the proposed the e-Prescribing program.
removal of physician-administered drugs from the www.gpoaccess.gov/fr/index.html
“physician services” portion of the physician update www.aans.org/legislative/aans/medical.asp
formula—and bonuses through the Physician
Quality Reporting Initiative. Proposal highlights
include: an update of practice expense relative
value units resulting in a 3 percent gain in reim- 8 GET IN THE LOUPE
bursement in this area; a change in the utilization Compelling digital photos that depict a contemporary event,
rate assumption for imaging equipment from the clinical topic or technique in neurosurgery are sought for the
current 50 percent utilization rate to a 90 percent In the Loupe photographic feature. Submission instructions
utilization rate for equipment costing over $1 mil- are accessible by selecting the link in the Write for AANS
lion; revisions to the methodology for calculating Neurosurgeon section of www.aansneurosurgeon.org.
malpractice relative value units; Physician Quality
Vol. 18, No. 2 • 2009 • WWW.AANSNEUROSURGEOn.ORG 3
FRONTLINES
Pain Improves With Both Real Better Microsurgical Skills by
and Simulated Vertebroplasty Neurofeedback Training
Relief of pain from vertebral compression fractures Neurofeedback training results in significant improve-
and improvement in pain-related dysfunction are ment in surgical technique and reduces surgical time,
similar in osteoporotic patients treated with vertebro- according to a study of trainee ophthalmic microsur-
plasty and those treated with simulated vertebroplas- geons in the U.K. published in BMC Neuroscience.
ty without cement injections, according to a double- Ros and colleagues assessed whether two different
blinded study by Kallmes and colleagues published in EEG neurofeedback protocols could develop surgical
the New England Journal of Medicine. Researchers skills. The surgeons were randomly assigned to one
from eight medical centers in the U.S., U.K. and Aus- of three groups, sensory motor rhythm-theta; alpha-
tralia studied 131 patients whose baseline character- theta; or a control group. The neurofeedback groups
istics of pain and function were similar. Within days received eight 30-minute sessions of EEG training
of treatment, both the vertebroplasty group and the followed by a posttest, which showed significant
W
control group showed similar improvements in func- improvements in both groups. The authors concluded
tion and pain. “We aren’t saying the vertebroplasty that neurofeedback training holds promise for opti-
doesn’t work, because it somehow does,” stated Dr. mizing surgical training.
Kallmes in a press release. “But both sets of patients www.biomedcentral.com/bmcneurosci
experienced significant improvements in pain and
function a month following the procedure, whether Neurosurgeon Tells Congress:
they received cement injections or not. Improve-
ments may be the result of local anesthesia, sedation, ‘Adequate Physician Workforce’
patient expectations, or other factors.” Includes Neurosurgeons
www.nejm.org That Congress must strive to maintain patient ac-
cess to vital specialty care such as neurosurgery was
‘Red Flags’ Rule Enforcement the message that neurosurgeon Robert E. Harbaugh,
Begins Nov. 1 speaking for the AANS and the Congress of Neuro-
logical Surgeons, delivered to the U.S. House of Rep-
The Federal Trade Commission is delaying enforce- resentatives Committee on Small Business in July. He
ment of the so-called red flags rule until Nov. 1. The described the current problems with patient access to
rule requires physicians and hospitals to adopt writ- neurosurgical care as acute and said that the situation
ten plans for tracking and responding to indicators will be compounded by an aging surgical workforce,
of identity theft in their billing operations. The FTC fewer medical students choosing a surgical career and
considers hospitals and physicians creditors under the a growing elderly population that will require more
rule because they accept deferred payment for services. interventional, rather than primary care, services. He
www.ftc.gov/opa/2009/07/redflag.shtm urged Congress to consider the following measures in
www.ftc.gov/bcp/edu/microsites/redflagsrule healthcare reform legislation:
www.ama-assn.org/ama/no-index/physician-
33 Establish a pediatric subspecialty scholarship and
resources/red-flags-rule.shtml
loan repayment program to encourage more physi-
cians to choose pediatric neurosurgery and other
Neurosurgeon Tapped for pediatric subspecialties in short supply.
CMS Advisory Panel 33 Fund demonstration programs to develop models
Neurosurgeon Gregory J. Przybylski is one of five for regionalizing emergency/trauma care.
new members appointed to the Advisory Panel on 33 Enact medical liability reforms.
Ambulatory Payment Classification Groups. All five 33 Repeal Medicare’s sustainable growth rate formula
appointments are for four-year terms beginning on and refrain from adopting payment policies that
Oct. 1. The panel reviews the APC groups and their enhance reimbursement for primary care physicians
associated weights for their clinical integrity and of- at the expense of specialty physician reimbursement
fers advice to the Department of Health and Human in a budget neutral model.
Services and the Centers for Medicare and Medicaid 33 Preserve Medicare funding for graduate medical
Services for consideration in the annual updates of education, eliminating the cap on Medicare’s support
the hospital outpatient prospective payment system. and refraining from redistribution of any unused
www.gpoaccess.gov/fr/index.html residency training slots solely to primary care.
4 Vol. 18, No. 2 • 2009 • AANS NEUROSURGEOn
W
This is not healthcare reform
While there is widespread acknowledgement that the U.S. health-
care system is not economically viable for much longer without some
sort of change, there remains little consensus on what healthcare re-
form should entail. The genuine window of opportunity for massive
health system reform has forced public officials and private citizens
alike to examine their individual views of healthcare rights and re-
sponsibilities in the context of American life. Many have floundered
when trying to articulate exactly what it is they want the U.S. health
system to look like. In this high stakes contest of idealism versus
pragmatism, the easier course is to identify and decry proposals with
which one does not agree. The more difficult course, as stakeholder
organizations and Congress can attest, is that of envisioning how
an optimal system would look and function, building it proposal by
proposal, and enacting legislation that embodies the vision.
At press time Congress had offered two proposals, one in the
U.S. House of Representatives and one in the Senate. Our cover
story reviews these proposals with a focus on aspects of interest to
neurosurgeons. In related articles, a neurosurgeon reviews health-
care reform enacted in Massachusetts and proposed in California,
and another scales Capitol Hill to make the case for meaningful
medical liability reform.
Vol. 18, No. 2 • 2009 • WWW.AANSNEUROSURGEOn.ORG 5
COVER FOCUS
Healthcare Reform
What Neurosurgeons Need to Know
KATIE O. ORRICO, JD
We now face an opportunity—and an obligation—to skepticism about the details of the effort to overhaul
turn the page on the failed politics of yesterday’s the nation’s healthcare system.
healthcare debates. … My plan begins by covering every For neurosurgeons, the legislation proposed
American. If you already have health insurance, the only thus far can be reduced to two basic themes: First,
thing that will change for you under this plan is the specialists and particularly surgeons are overpaid
amount of money you will spend on premiums. That will while primary care doctors are underpaid; there-
be less. If you are one of the 45 million Americans who fore healthcare reform legislation must increase
don’t have health insurance, you will have it after this fees paid to primary care physicians and focus
plan becomes law. No one will be turned away because more resources on preventive services. Second,
of a preexisting condition or illness. the healthcare delivery system must be retooled to
C
— Barack Obama, Speech in Iowa City, Iowa, May 29, 2007 focus on quality rather than quantity; therefore
tests, procedures and expensive technology should
ost, coverage and choice. be eliminated in the absence of proven benefit to
The debate over healthcare patient care and health outcomes.
reform largely boils down to
these three topics, although The Environment for Health Reform
within each there are com- Much has been made about past failed attempts at
plicated and controversial enacting national health system reform, from the
issues under consideration days of President Franklin D. Roosevelt through the
as Congress and the White administration of President Bill Clinton. There have
House attempt to move been many reasons cited for these failures, including
healthcare reform legislation forward. the complexity of the issues, ideological differences,
The Obama administration has identified the fol- the lobbying of special interest groups, and the
lowing fundamental goals for comprehensive health lack of individuals willing to make personal sacri-
reform: fices. However, it seems that passage of meaningful
33 Reduce long-term growth of healthcare costs for healthcare reform legislation this year is possible if
businesses and government. not probable. From a political standpoint, there are
33 Protect families from bankruptcy or debt because a number of key differences that exist today com-
of healthcare costs. pared to the last attempt at major health
33 Guarantee choice of doctors and health plans. system reform in 1994.
33 Invest in prevention and wellness.
33 Improve patient safety and quality of care.
33 Ensure affordable, quality health coverage for all
Americans.
33 Maintain coverage for those who change or lose
their jobs.
33 End barriers to coverage for people with pre-
existing medical conditions.
Clearly, these are laudable goals and most would
agree necessary elements of meaningful health system
reform. But as history and the legislative process
this year in Congress can attest, they are more easily
proposed than achieved. Even as the support of the
American public for some kind of healthcare reform
remains fairly solid, opinion polls suggest increasing
6 Vol. 18, No. 2 • 2009 • AANS NEUROSURGEOn
Both then and now, the Democrats controlled
the White House, House of Representatives and
Senate, and the president made healthcare reform
a centerpiece of his domestic agenda. However, in
addition to holding a sizable majority in the House,
the Democrats now number 60 in the Senate. This
is the magic number necessary for a political party
to invoke cloture—a procedural device that cuts
off debate and prevents a filibuster. Congress also
has passed a resolution allowing it to bypass regu- written, the details of the legislation that are emerg-
lar order and consider healthcare reform in what is ing largely reflect the vision of President Obama and
called the budget reconciliation process. This fallback the Democrats in Congress. The list of issues affect-
procedural approach would allow reform legislation ing neurosurgeons is long, and organized neurosur-
to pass with only a simple majority in each chamber gery is working to ensure that the final legislation
of Congress. reflects neurosurgery’s position on healthcare reform
Policymakers also feel more compelled to move (see AANS/CNS Position on Healthcare Reform,
forward this year because the ranks of the uninsured page 12).
have risen from 37 million in 1994 to nearly 47 mil- The principal bill under consideration in the
lion in 2009. In addition, fewer Americans are now House is the America’s Affordable Health Choices
covered by employer-sponsored health insurance. Act, H.R. 3200. This bill has been amended by
Many people believe that the most important the three House committees with jurisdiction over
difference between then and now, and what makes healthcare reform—Ways and Means, Energy and
health reform a must, is the explosion of healthcare Commerce, and Education and Labor—and now
costs. In 1994, health spending was approximately must be reconciled into a final version by the speaker
13 percent of gross domestic product; in 2009 it is of the House and the House Rules Committee, which
nearly 18 percent of GDP. Medicare and Medicaid is controlled by the speaker.
spending as a percentage of GDP also has risen from In the Senate, the Health, Education, Labor and
3.5 percent to nearly 5 percent. Costs of employer- Pensions Committee, known as HELP, amended the
provided health benefits have doubled, the unem- aspects of reform under its jurisdiction, including
ployment rate stood at 9.7 percent in August com- issues related to coverage, health plan standards,
pared to 6.5 percent in 1994, and the budget deficit quality, and public health, but not issues related
as a percentage of GDP is now over 13 percent to Medicare and Medicaid or financing, which are
compared to 2.9 percent in 1994. under the control of the Finance Committee. The
Lastly, the Obama administration reportedly has Finance Committee has yet to release its version of
made a number of “deals” with many key stakehold- the bill, and Chairman Max Baucus, a Montana
ers to get them to support rather than oppose (as Democrat, and Charles Grassley of Iowa, the se-
they did in 1994) reform efforts. Groups that have nior Republican on the committee, are attempting a
announced some kind of support for the president’s bipartisan approach to reform. However, the Finance
efforts include the American Medical Associa- Committee released three option papers in the spring
tion, American Hospital Association, America’s that signaled the direction it is taking.
Health Insurance Plans, and Pharmaceutical Some key reform legislation provisions of particu-
Research and Manufacturers of America. lar interest to neurosurgeons follow.
Whether altogether these factors will
be enough to achieve healthcare reform Protections and Standards for Health Plans
remains to be seen, but the chances for 33 Insurance Reforms Legislation in the House and Sen-
reform may be better now than at any ate includes a number of reforms to the health in-
other time in our nation’s history. surance marketplace. It prohibits the application of
preexisting condition exclusions; requires guaran-
Details of the Health Reform Legislation teed issue and renewal of insurance policies; ensures
While the final chapter on healthcare the adequacy of provider networks; and limits the
reform is not even close to being variation in health insurance premiums.
Vol. 18, No. 2 • 2009 • WWW.AANSNEUROSURGEOn.ORG 7
COVER FOCUS
33 Basic Benefits The House and Senate bills require opt out. For the first three years, physician reim-
health plans to cover certain basic benefits. Under bursement rates will be based on Medicare plus 5
the House bill the benefit package would be devel- percent. However, in subsequent years, the U.S. De-
oped by the Health Benefits Advisory Committee, partment of Health and Human Services will have
chaired by the U.S. Surgeon General. At least one the authority to set rates—higher or lower—and
practicing physician must be a member of this com- physicians will have no administrative or judicial
mittee. The Secretary of the Department of Health recourse to challenge payment rates. Furthermore,
and Human Services would determine the benefit HHS may use “innovative payment mechanisms
package under the Senate bill. and policies” such as bundling, accountable care
organizations, pay for performance, and the medi-
33 Consumer Protections The House and Senate bills cal home, to reimburse physicians under the public
require health plans to meet certain marketing stan- plan. Medicare balanced-billing limitations apply
dards. They are required to establish a timely inter- as do Medicare’s fraud and abuse rules. The Sen-
nal grievance and appeals mechanism and establish ate has not finalized its policy on the public health
an external review process for denied claims. Under insurance option.
the House bill claims must be paid on a timely ba-
sis, based on Medicare’s current rules. Tax Code Changes
The House bill makes a number of changes to the
The House legislation
33 Health Choices Commissioner current tax code to achieve universal coverage.
creates the Health Choices Commissioner role, Employers have certain cost-sharing requirements
which is responsible for overseeing and enforcing for health insurance coverage, and those choosing
the health plan rules. The commissioner can col- not to provide coverage must pay an excise tax of 8
lect data for the purpose of promoting healthcare percent of average employee wages. Individuals who
quality and value and may share such data with the do not have health insurance coverage are required
federal government. to pay a tax of 2.5 percent. Universal coverage also is
paid for, in part, through increased income taxes on
Health Insurance Exchange and the those who make over $350,000 per year as follows:
Public Health Insurance Option $350,000–$500,000, 1 percent; $500,000–$1 mil-
33 Health Insurance Exchange The House and Senate lion, 1.5 percent; and over $1 million, 5.4 percent.
legislation creates a nationwide Health Insurance
Exchange, or gateway, to give people the ability to Medicare Improvements
choose from a variety of health plans. All individu- 33 Sustainable Growth Rate In the House bill, the $245
als are eligible to purchase an exchange plan, as are billion debt accumulated under the sustainable
those whose existing employer coverage is deemed growth rate formula is erased, and the new target
insufficient by the federal government. Once growth rate system replaces the SGR. The TGR is
deemed eligible to enroll, individuals would be basically identical to the SGR except that there are
permitted to remain in the exchange until becoming two expenditure targets—one for primary care and
Medicare-eligible. preventive as well as evaluation and management
services, and one for all other services. In addition,
33 Benefits Underthe House bill, the Health Choices the physician spending growth rate is slightly high-
Commissioner specifies the benefits to be made er. Spending for primary care services is permitted
available through exchange-participating plans. The to grow at the rate of gross domestic product plus 2
commissioner also determines network adequacy percent, and all other services are allowed a growth
and establishes cost-sharing for out-of-network target of GDP plus 1 percent. The details of the
services. Under the Senate bill, the Secretary of HHS Senate proposal are not known at this time, but it is
undertakes these functions. expected that the Senate will neither repeal the SGR
nor forgive the debt. Rather, the Finance Committee
The House bill autho-
33 Public Health Insurance Option proposal is likely to include only another temporary
rizes the federal government to operate a low-cost “fix” to prevent the 22 percent physician payment
health insurance plan. The plan is capitalized with cut in 2010, replacing it with a modest increase in
$2 billion from the federal treasury. Physicians who physician reimbursement.
participate in Medicare will be enrolled automati-
cally as providers in the public plan, but they can
8 Vol. 18, No. 2 • 2009 • AANS NEUROSURGEOn
33 Misvalued Codes Under the Medicare Physician Fee cians practicing in areas that are identified as being
Schedule The House bill requires the HHS secretary the most cost-efficient areas of the country. The Sen-
to periodically identify “misvalued” codes used ate is considering options that would cut payments
under the physician fee schedule. It further calls to those physicians in areas that are deemed cost-
for appropriate adjustments to the relative values inefficient.
associated with those codes by identifying the codes
that have the fastest growth or substantial changes 33 Physician Quality Reporting Initiative The House bill ex-
in practice expense, codes for new technologies, and tends through 2012 the current 2 percent bonus paid
multiple codes that frequently are billed for a single under the Physician Quality Reporting Initiative. The
service. The bill also requires the HHS secretary to Senate is considering options that would extend the
establish a process to validate relative value units bonus payment through 2010, but after that physi-
under the physician fee schedule. This “shadow cians would be required to participate in PQRI or
RUC” is in addition to the American Medical As- have their fees cut to a maximum of 5 percent.
sociation’s Relative Value Update Committee, which
currently values physician work. Similarly, the Sen- 33 Payment for Imaging Services The House bill decreases
ate Finance Committee released an options paper reimbursement for the technical component of im-
that demonstrates its interest in establishing an aging services, which would affect those physicians
expert panel to assist the Centers for Medicare and who own and operate imaging equipment. The
Medicaid Services in evaluating and adjusting pay- Senate is considering development and utilization
ment for potentially misvalued physician services. of appropriateness criteria for ordering diagnostic
imaging services and requiring physicians to report
33 Payment for Efficient Areas The
House legislation utilization data on designated imaging procedures,
provides a 5 percent incentive payment for physi- including those for low back pain, musculoskeletal
The Healthcare Reform Players
While there are many policymakers Key Committees for Healthcare Reform SENATE
involved in the healthcare reform 33 Education and Labor Committee, 33 Majority Leader – Harry Reid, D-Nev.,
debate, these are the key political http://edlabor.house.gov http://reid.senate.gov
players in Washington, D.C. 33 Chairman – George Miller, D-Calif. 33 Minority Leader – Mitch McConnell, R-Ky.,
33 Ranking Member – John Kline, R-Minn. http://mcconnell.senate.gov
Obama Administration
President – Barack Obama, 33 Energy and Commerce Committee, Key Committees for Healthcare Reform
www.whitehouse.gov http://energycommerce.house.gov 33 Finance Committee,
33 Director of the White House Office of
33 Chairman – Henry Waxman, D-Calif. http://finance.senate.gov
Health Reform – Nancy Ann DeParle, 33 Ranking Member – Joe Barton, R-Texas 33 Chairman – Max Baucus, D-Mont.
www.healthreform.gov 33 Health Subcommittee Chairman – 33 Ranking Member – Chuck Grassley, R-Iowa
33 Secretary of the Department of
Frank Pallone Jr., D-N.J.
33 Health, Education, Labor and
Health and Human Services – 33 Health Subcommittee Ranking Member –
Pensions Committee,
Kathleen Sebelius, Nathan Deal, R-Ga.
http://help.senate.gov
www.hhs.gov 33 Ways and Means Committee, 33 Chairman – Edward Kennedy, D-Mass.
http://waysandmeans.house.gov (During Sen. Kennedy’s illness, Christopher
House of Representatives 33 Chairman – Charles Rangel, D-N.Y. Dodd, D-Conn., oversaw the HELP
33 Speaker of the House – Nancy Pelosi, D-Calif., 33 Ranking Member – Dave Camp, R-Mich. committee. Following Sen. Kennedy’s
http://speaker.house.gov/ 33 Health Subcommittee Chairman – death in August, a new chairman has
33 Majority Leader – Steny Hoyer, D-Md., Pete Stark, D-Calif. not been named.)
www.majorityleader.gov/ 33 Health Subcommittee Ranking Member – 33 Ranking Member – Michael Enzi, R-Wyo.
33 Minority Leader – John Boehner, R-Ohio, Wally Herger, R-Calif.
http://republicanleader.house.gov/
Vol. 18, No. 2 • 2009 • WWW.AANSNEUROSURGEOn.ORG 9COVER FOCUS
disease and headaches. Physicians identified as order- 33 Increased Payments to Primary Care Physicians The
ing too many tests to treat these conditions would House bill gives primary care physicians a 5 percent
then face a 5 percent cut in Medicare payment. bonus payment. The Senate is considering an option
that would give them a 10 percent bonus payment,
The House legislation prohibits
33 Specialty Hospitals of which 5 percent would be budget neutral. That
physician ownership of new specialty hospitals, but is, 5 percent would be reallocated from the pool of
grandfathers the ownership of all physician-owned funds paid to nonprimary-care physicians.
hospitals existing prior to 2009. Existing hospitals
are permitted to expand in a limited fashion. The Quality Improvement
Senate is likewise considering this option. 33 Comparative-Effectiveness Research The House bill
establishes the Center for Comparative Effective-
Promoting Primary Care and Coordinated Care ness Research within the Agency for Healthcare
33 Accountable Care Organizations The House legislation Research and Quality to conduct, support and
authorizes pilot programs to develop alternative synthesize research that compares the effectiveness
payment models based on the concept of account- of healthcare items and services. The legislation
able care organizations. ACOs can include groups calls for a 15-member commission to govern the
of physicians organized around a common delivery center and prohibits the center and the commission
system (e.g., a hospital), an independent practice as- from mandating coverage, reimbursement or other
sociation, a group practice or other common prac- policies to any public or private payer. The Senate
tice organizations. ACOs that reduce overall costs is considering establishment of an independent CER
and meet certain quality targets will be financially entity outside of the federal government and more
rewarded. HHS is authorized to implement ACOs protections to ensure that the research focuses on
on a permanent basis if the HHS secretary deter- clinical effectiveness, not cost effectiveness, and is
mines that they result in less spending. The Senate guided by expert advisory panels subject to a peer-
also is likely to include a provision aimed at moving review process, with adequate opportunity for pub-
more physicians into ACOs. lic comment. The Senate also supports appropriate
firewalls to ensure that the CER institute could not
Legislation in the House and Senate
33 Medical Home mandate coverage or reimbursement policies.
expands the current medical home pilot projects
under which primary care physicians are paid ad- 33 Quality MeasuresThe House and Senate legisla-
ditional money to coordinate patient care. tion requires HHS to establish national priorities
for performance improvement and to develop new
quality measures that reflect these priorities and
assess the efficiency and resources used in providing
medical care.
President Obama has 33 Best Practices The House bill creates the Cen-
called on Congress to ter for Quality Improvement and charges it with
identifying, developing, evaluating, disseminating,
send him a bill to sign and implementing best practices in the delivery of
healthcare services.
by October, but most Physician Payments Sunshine
observers believe that Both the House and Senate bills contain provisions
requiring manufacturers and distributors of drugs,
is impossible. devices, biological products or medical supplies to
report to the government any payments or other
transfers of value to physicians that exceed $5.
Fraud and Abuse
The House and Senate bills contain increased penal-
ties for Medicare fraud and abuse and give the Cen-
ters for Medicare and Medicaid Services increased
10 Vol. 18, No. 2 • 2009 • AANS NEUROSURGEOnAdvantages and Disadvantages of Potential Medical Liability Reforms
Reform Advantages Disadvantages
Disclosure-and-offer • Would promote transparency regarding • Might be opposed by trial attorneys because
programs medical errors their role would be somewhat reduced
• Are reportedly effective at the institu- • Involve risk for healthcare providers because
tional level in reducing volume and costs of patients would be told of medical errors and
lawsuits might choose to sue
• Would reduce length and adversarial • Evidence base for effectiveness in reducing
nature of claiming process costs consists solely of programs’ self-reports
• Are unlikely to be opposed by patients’
groups because patients’ participation
would be voluntary
Administrative or • Would improve predictability of litigation • Would probably be opposed by trial attorneys
specialized tribunals outcomes through greater use of decision because their role would be reduced
guidelines and enterprise
• Might be opposed by patients’ groups because
• Would replace “battles of the experts”
access to court would be restricted and awards
with use of neutral experts or expert
might be lower
adjudicators
• Might face fights over constitutionality
• Might promote physicians’ uptake of
comparative-effectiveness research and • Evidence base for effectiveness in reducing
adherence to practice guidelines costs is small
• Might reduce length and adversarial
nature of litigation process
“Safe harbors” for • Would probably reduce costs if guidelines • State-level experiments showed that cases in
adherence to for damages awards were adopted which physicians could invoke safe harbors were
evidence-based practice infrequent
• Would promote physicians’ update of
comparative-effectiveness research and • Unclear how many lawsuits would be
practice of evidence-based care prevented
• Might streamline adjudication of some • Would not affect size of damages awards
cases
• Might control costs by reducing the pro-
portion of cases in which plaintiffs prevailed
Source: Mello MM, Brennan TA: The role of medical liability reform in federal healthcare reform. N Engl J Med 361:1–3, 2009; Copyright © 2009
Massachusetts Medical Society. All rights reserved.
The House and Senate bills available at press time did not include measures that could be characterized as meaningful liability reform.
Some of the measures under discussion are analyzed above. Disclosure-and-offer programs also are known as “early disclosure” or “early
offer” programs. Administrative or specialized tribunals are frequently called health courts.
authority to implement programs to prohibit waste, tion, the bills in both the House and Senate establish
fraud and abuse. medical student loan repayment programs for those in
identified health professional shortage areas, including
Physician Workforce primary care and general surgery. The legislation also
The House and Senate legislation implements a num- provides grant funding to establish pilot projects for
ber of policies to encourage more medical students the regionalization of trauma and emergency care.
to go into primary care. It allocates unused residency
positions funded by Medicare to primary care and Prevention and Wellness
funnels graduate medical education funds to residency The House and Senate bills also contain extensive
training programs in nonhospital settings. In addi- Continues on page 13 0
Vol. 18, No. 2 • 2009 • WWW.AANSNEUROSURGEOn.ORG 11COVER FOCUS
AANS/CNS Position on Healthcare Reform
T
he American Association of Neuro- healthcare system, it is riddled with provisions that
logical Surgeons and the Congress of are detrimental to physicians and patients and, if
Neurological Surgeons strongly sup- enacted, this legislation could amount to a complete
port reforming our nation’s health- government takeover of healthcare. The following
care system. The AANS and CNS underscores some of the reasons for the AANS/CNS
believe that Congress should enact a course of action:
carefully targeted set of reforms that 33 No effective medical liability reforms are includ-
are based on organized medicine’s ed in the bill.
longstanding principles and policies. The funda- 33 The government will determine standards of
mental tenets of reform include those outlined in medical care by identifying, developing, evaluat-
the American Medical Association’s vision of health ing, disseminating, and implementing best prac-
system reform: tices in the delivery of healthcare services.
33 Ultimately, the public health insurance option
33 Protect the sacred relationship between patients will lead to a single-payer, government-run
and their physicians, without interference by healthcare system.
insurance companies or the government. 33 Under the public health insurance option, the
33 Provide affordable health insurance for all government is empowered to implement rules
through a choice of plans. that would restrict a patient’s choice of physician
33 Eliminate denials for preexisting conditions. and limit timely access to quality specialty care.
33 Promote quality, prevention and wellness 33 The bill fails to recognize the looming workforce
initiatives. shortages in surgery in its requirement that all
33 Repeal the Medicare physician payment system unused medical residency training slots be al-
that harms seniors’ access to care. located to primary care and in its placement of
33 Ease the crushing weight of medical liability and the emphasis on national workforce policy on
insurance company bureaucracy. primary care to the exclusion of surgical and
In addition, the AANS and CNS are pursuing other specialty care.
reforms that allow patients and physicians to take a 33 The bill inappropriately expands the govern-
more direct role in their healthcare decisions, and be- ment’s involvement in determining the quality of
lieve that a patient-centered healthcare system should medical care and residency training programs.
adhere to the following principles: 33 The bill permits the government to arbitrarily
33 Every person in the United States should have the reduce reimbursement for valuable, lifesaving
ability to choose his or her health plan. specialty care for elderly patients, threatening to
33 Patients should have the right to choose their limit their treatment options.
doctors and to enter into agreements as to the 33 Patient-centered healthcare is threatened by
fees for those services. provisions related to comparative-effectiveness
33 The determination of quality medical care must research, changes to office-based imaging and
be made by the profession of medicine, not by limitations on development of physician-owned
the government. specialty hospitals.
In evaluating the House bill (which at press time 33 The bill potentially stifles medical innovation and
was the only “comprehensive” reform bill un- valuable continuing medical education programs.
veiled), unlike other major physician organizations,
the AANS and CNS did not believe that a false The AANS and CNS are active players in the health-
promise of reform of the sustainable growth rate care reform debate, working closely with the Alliance
formula was worth the long-term detrimental ef- of Specialty Medicine, the Surgical Coalition, Doc-
fects of H.R. 3200, the America’s Affordable Health tors for Medical Liability Reform, the Partnership to
Choices Act. The AANS and CNS opposed this bill Improve Patient Care and a loose confederation of
because as currently constructed it goes far beyond state medical associations, to achieve meaningful, but
what is necessary to fix what is broken with our reasonable, health system reform legislation. NS
12 Vol. 18, No. 2 • 2009 • AANS NEUROSURGEOn0 Continued from page 11
on Congress to send him a bill to sign by October,
sections focusing on wellness and prevention and cre- but most observers believe that it is impossible to
ate a number of new programs aimed and improving meet this deadline and that it is more realistic to look
the nation’s overall health. at passage just before or after Thanksgiving—assum-
ing Congress can pass a bill at all.
Medical Liability Reform Left out of the Legislation Given the politics, particularly on such wedge is-
From the perspective of most physicians, the House sues as the public health insurance option, individual
and Senate bills cannot be considered comprehen- and employer coverage mandates and increased
sive healthcare reform because they do not include taxes, plus the trillion dollar price tag, odds for pass-
any meaningful medical liability reform. It is well ing “comprehensive” reform are probably 50–50 at
documented that medical liability reform is crucial to best. Despite these steep odds, it is virtually certain
protecting patients’ access to quality care and slow- that Congress will pass some form of healthcare
ing the rising cost of healthcare. The inefficiencies of legislation this year. One of the key incentives to act
the current medical liability system, escalating and is the looming 22 percent Medicare physician pay
unpredictable awards, and the high cost of defending cut scheduled to go into effect on Jan. 1, 2010. Few
against lawsuits, even those without merit, contribute members of Congress would want to go home for the
to the increase in medical liability insurance premi- December holidays without having fixed this prob-
ums, which are at or near all-time highs. As insur- lem. There also are other issues on which Congress
ance becomes unaffordable or unavailable, physi- and the president are likely to reach bipartisan con-
cians must make tough decisions, including altering sensus, including improvements for primary care and
or limiting their services because of liability concerns, the implementation of some health system reforms,
which impedes patient access to care. In addition, the such as the creation of the health insurance exchange
cost of the liability system is borne by everyone as and eliminating preexisting conditions exclusions.
defensive medicine adds billions of dollars to the cost In the end, especially if the majority of Americans
of healthcare each year, which means higher health are basically happy with their current health cover-
insurance premiums for patients. age, as most polls demonstrate, any reform legisla-
Last October, then-candidate Barack Obama tion that achieves passage is likely to fall short of the
wrote in the New England Journal of Medicine that president’s proposed fundamental goals. However,
he would be “open to additional measures to curb neurosurgeons can expect that the interest in and em-
malpractice suits and reduce the cost of malpractice phasis on physician payment and healthcare quality
insurance. We must make the practice of medicine will intensify and that there are sure to be changes in
rewarding again.” The AANS, with the Congress of these areas. NS
Neurological Surgeons and other coalition partners,
Katie O. Orrico, JD, is director of the AANS/CNS Washington office.
are pressing Congress and President Obama to heed
these words and include effective medical liability Healthcare Reform Resources
reform in the final healthcare reform bill. The following Web sites offer key information on the policy options under
consideration from a variety of perspectives:
Outlook for Reform 33AANS Neurosurgery and Healthcare Reform, www.aans.org/
As of press time, it is hard to predict the outcome of legislative/aans/Neuro_HealthCareReform.asp
the healthcare debate. The three House committees 33American Medical Association Vision for Healthcare
with jurisdiction over healthcare reform have com- Reform, www.ama-assn.org/ama/pub/advocacy/health-
pleted their work, and a final version of the House system-reform.shtml
33Congressional Budget Office, www.cbo.gov
bill likely will be drafted and voted on by the House 33Kaiser Family Foundation, http://healthreform.kff.org
of Representatives sometime between late September 33New England Journal of Medicine Health Care Reform Center,
and mid-October. In the Senate the HELP Committee http://healthcarereform.nejm.org/?query=rthome
finalized its version of health reform legislation, but 33U.S. Department of Health and Human Services Health Re-
the critical Finance Committee has yet to produce a form, www.healthreform.gov/
bill, although, as previously noted, this committee 33U.S. House of Representatives—House Republican Conference,
has done quite a bit of preliminary work on various www.gop.gov/solutions/healthcare/resources
33U.S. House of Representatives—Office of the Majority Leader,
policy options for inclusion in its version of reform www.majorityleader.gov/members/health_care.cfm
legislation. Once the Finance Committee completes 33U.S. Senate Finance Committee, http://finance.senate.gov/
its work, a final bill must be drafted for consider- healthreform2009/home.html
ation by the full Senate. President Obama has called 33U.S. Senate Republican Congress, http://src.senate.gov/public
Vol. 18, No. 2 • 2009 • WWW.AANSNEUROSURGEOn.ORG 13COVER FOCUS
Medical Liability Reform
A Critical Component of Patient Access to Care
A Digest of the Statement of James R. Bean, MD, to the The effect on patient access to care and the physi-
U.S. House of Representatives Energy and Commerce cian population has been so severe that many doctors
Subcommittee on Health have been forced to retire early, move out of those
T
states where the crisis is most acute, and cut back
hank you for giving me this opportunity to on the kinds of life-saving and life-enhancing medi-
address you on the critical issue of patient cal procedures that expose them to greater risk of
access to medical care. lawsuit abuse.
Access to effective medical care depends While the immediate shortages of physician care
on a number of factors, but one that’s too often ne- caused by the liability crisis are severe, the outlook
glected is the barrier to access created by a malfunc- for the future is even more troubling. Fears of expo-
tioning medical liability system. sure to lawsuit abuse are causing medical students
I think we can safely say that there is near uni- and residents to avoid high-risk specialties and more
versal agreement among physicians, patients, policy litigious states.
experts, opinion leaders, and policymakers on both As rates began to slow their rapid climb and level
sides of the aisle that our current medical liability off in 2006, some were tempted to say that the crisis
system is broken and does not best serve the needs of had passed. In fact, while rates have declined some-
patients or physicians. what, they remain at or near historically high levels.
It is also widely recognized that we will never be According to the Medical Liability Monitor for
able to control costs if we don’t do something about 2008, more than 50 percent of rates did not change
the constantly overhanging fear of lawsuits that between 2007 and 2008. Some seven percent of
drives physicians and hospitals to increasingly prac- premiums increased. While the remaining 43 percent
tice defensive medicine. of rates decreased, most of those decreases were
According to Elliot Fisher of the Dartmouth Insti- small—less than 10 percent. This is after premium
tute for Health Policy, the overuse of imaging services increases over 100 percent a year in some states with-
driven by medical liability fears was associated with out comprehensive medical liability
an increase in total Medicare spending of more than reforms in place.
$15 billion between 2000 and 2003. Updated figures For the years 2000 to 2008:
for the findings of a 2003 HHS report on the overall 33 Premiums rose 221 percent for
costs of defensive medicine put it at an astounding OB-GYNs in Philadelphia, Pa.
$170 billion per year. 33 Premiums rose 149 percent
Lawsuit abuse has gotten so out-of-control that for general surgeons
about one-third of orthopedists, obstetricians, in New Jersey.
trauma surgeons, emergency room doctors and plas- 33 Premiums rose 348 per-
tic surgeons can expect to be sued in any given year. cent for internists in
Practicing neurosurgeons can expect to be sued even Connecticut.
more often—every two years, on average. Continues on page 16 0
Most of these cases are meritless: Data for 2006
show that some 71 percent of cases are dropped
or dismissed, and only 1 percent of cases result in
a verdict for the plaintiff. Nevertheless, the cost
is staggering, with even those cases that result in
no payment to the plaintiff costing an average of
$25,000 to defend against. Meanwhile, the average
jury award escalated from about $347,000 in 1997
to $637,000 in 2006.
14 Vol. 18, No. 2 • 2009 • AANS NEUROSURGEOnAANS on Capitol Hill: A Personal Perspective
A
Michael Schulder, MD
“
ccess to quality care must come provement in physician recruitment and access after
first in overall healthcare reform. voters passed an amendment that limited noneco-
That is what it is all about, after nomic damages in malpractice cases, was made plain.
all. And ensuring patient access Dr. Bean noted other potential reforms, including
to care means acting now to fix use of an “early offer” model, under which plaintiffs
our critically ill medical liability are held to a higher burden of proof after rejecting a
system.” settlement that pays economic damages and lawyers’
With these words James R. fees; specialized health courts with real authority to
Bean, the 2008–2009 AANS president, concluded his issue binding judgments; and the protection from
testimony on March 24 before the House Energy and legal action by practitioners who follow evidence-
Commerce Subcommittee on Health. It was the last based guidelines.
of three hearings on “Making Health Care Work for
American Families.”
Most hearings of Congressional committees are
It is vital to state your
not heavily publicized, broadcast or webcast. They
can go on seemingly forever as a series of speakers
case clearly, briefly,
hold forth before their bored audience of elected
officials and public observers. In other words, they
and forcefully.
resemble committee meetings anywhere. When Con- The presentation by Dr. Bean was compelling, es-
gressmen are there at all they may use the occasion to pecially in comparison to some of the other speakers,
posture for their constituents. Yet this is where much in ways that are instructive to anyone planning to
of the business of governing happens, where bit by make their case with Congress. Stay focused on your
bit information is gathered and where it is possible to message. If your goal is to discuss liability reform,
influence the creation of policy that affects us all. don’t dilute the presentation by bringing up other
The date of this hearing coincided with the 2nd topics, however worthy (such as avoiding surgical
Joint Surgical Advocacy Conference, during which fee reductions to pay for other needs in the health-
surgeons from various specialties converged on care system). Be concise—don’t take 20 minutes to
Capitol Hill to advance our common interests. state your case if you can do it in half the time. Keep
Conference attendees were visiting with Congress- graphs and charts simple and easy to read. Know
men or staffers while the hearing was being held. For your audience and stay clear of jargon: for instance,
much of the hearing there was a standing-room-only after one speaker discussed the “GME” (graduate
crowd. Chairman Frank Pallone opened the meeting medical education) system for some time, one of the
and laid out the goal of hearing the speakers propose representatives made clear his confusion between
ways to improve patient access to care. medical student and resident education. And back up
Of the speakers, Dr. Bean was the only surgeon. your assertions and your proposals with facts.
Others were internists, healthcare economists, a Members of Congress are busy dealing with
pediatrician, and a neurologist. They addressed such many people with many different concerns, and with
issues as training more primary care physicians and their own ambitions and lives. Even the whole of
paying them better, increasing the number of doc- healthcare reform is only a part of the Congressional
tors in rural America, and eliminating disparities in agenda, and to be sure the territory occupied by neu-
healthcare delivery among different ethnic groups. rosurgery is a very small fraction of that. That is why
Dr. Bean spoke on the need for medical liability it is vital to state your case clearly, briefly, and force-
reform, and he was the only speaker to address this fully before Congress, as Dr. Bean did so well. NS
issue. He explained, with supportive evidence, that
the defensive medicine that arises out of the fear of Michael Schulder, MD, is co-associate editor of the AANS Neurosurgeon. He is
vice chair of the Department of Neurosurgery and director of the Harvey Cush-
being sued costs as much as $170 billion a year. The ing Brain Tumor Institute at the North Shore Long Island Jewish Health System,
example of Texas, which experienced a dramatic im- Manhassett, N.Y. The author reported no conflicts for disclosure.
Vol. 18, No. 2 • 2009 • WWW.AANSNEUROSURGEOn.ORG 15You can also read
