CANS NEWSLETTER—January 2006

1.  CANS—round 1—Board meeting
2.  CANS—round 2—Annual meeting
3.  CANS—round 3—President’s Message
4.  CANS—round 4—Officers for 2006

1.  CANS in San Diego —the Board meeting
I am always impressed with how much time it takes for volunteer Boards of Directors of professional organizations to have a meeting.  But if one recognizes that meetings of the board members are where the work really gets done and the important decisions really made, then the time spent becomes appropriate, particularly in an organization like CANS with only three board meetings a year.  That said, the 5-hour board meeting on 1/13/06 was eventful.
Item 1.  Our lobbying firm principal, John Norwood, spoke for about 30 minutes during which time he made a number of points:
            1. His organization didn’t do well establishing communication with CANS.
            2. He thinks we are too small to get into the routine lobbying game.
            3. He feels the Vargas bill to freeze work comp fees at present levels is dead
                mostly because of opposition from labor who sees more money for docs as
                resulting in less money for workers; they don’t detect a potential access
                problem if our fees are heavily reduced.
            4. He expects the state work comp director to issue a new fee schedule in the
                spring; it will be an RBRVS system probably at 120% of Medicare rates
                which won’t become effective until late Summer.
            5. He thinks the state work comp director reflects the position of the admin-
                istration, cannot be lobbied and our only hope to improve # 4 (above) is to get our
                position on a better deal (see Item 2) directly before the Governor through
          some special contact person which he doesn’t have.

Following his presentation, the board voted to terminate our contract with him.  President Edwards then named an ad hoc committee chaired by Dr. Abou-Samra, our new 1^st Vice President, to study how to best employ the lobbying money we now collect as part of the increased dues structure.  Report due at the spring board meeting.

Item 2.  Steven Levine, M.D., a leader in the Association of California Neurologists, presented his plan to have the new work comp fee schedule be 120% of Medicare but with whatever existing fees that are greater than 120% of Medicare be “grandfathered” to remain at present levels until overtaken by inflation and raises in Medicare rates.  He estimates that would put work comp costs at an average of 131.7% of Medicare for now gradually narrowing to 120% over time.  He makes a pretty good case for how pushing comp rates to 120% of Medicare or less has created real access problems in other states.  The board voted to support his proposal but not fund a focused lobbyist effort to convince the administration to give this plan real consideration.  It would seem that this concept needs a buy-in by the Governor that a blanket 120% of Medicare would create access problems.  This writer thinks it will because with the discount docs are forced to give to get into Medical Provider Networks, comp fees are likely to be pretty close to Medicare rates and dealing with the comp system for that kind of pay may well discourage at least specialists from participating.  There is some thought that the administration and the employer lobby is willing to have access become a problem if not a crisis before giving increased provider pay any consideration.

Item 3.  Charles Bond, an attorney, presented his concept of forming a statewide organization that would assist neurosurgeons in bargaining with hospitals for ED/Trauma coverage.  Said organization, with the potential name of California Emergency & Neurosurgical Trauma Services (CENTS), would conduct an area/regional evaluation of the fair market value of coverage, then negotiate with hospitals.  One could envision this working in the Los Angeles region where Bill Caton has cobbled together about 20 like-minded neurosurgeons to cover 9-10 trauma hospitals (all of which pay some stipend for coverage) and if all those neurosurgeons were represented by CENTS, the stipends could well be improved with such a united approach (the anti-trust implication of such a united approach could be dicey).  Just how CENTS would work in San Diego , where there is no leader like Dr. Caton, coverage stipends range from zero to $2000+/24 hours and whose neurosurgeon’s most consistent single point of agreement is how much they dislike each other, is not clear.  The cost of creating CENTS would initially be $50K to create a business plan with additional costs to do a feasibility study and run the whole idea by government agencies to get a favorable anti-trust ruling.  Mr. Bond estimates the final cost would run about $25K per neurosurgeon member.  The Board endorsed the concept but committed no money to help form it.  (Don Prolo subsequently presented the results of the CANS survey indicating a modest interest by neurosurgeons in funding the $50K start up cost but the survey did not ask about interest in paying $25K per neurosurgeon for a functioning bargaining unit.)  Just what happens next is not clear.

Item 4.  The active members of CANS now number 167, down from 227 this time last year.  With the 167 paying $500/year dues, the organization is more solvent than when the 227 were paying $250.  No change in dues for active members in 2006.

2.  CANS in San Diego —the annual meeting
The Saturday morning socioeconomic session was very interesting.  Highlights:
Item 1.  Martha Marsh, CEO of Stanford Hospitals and Clinics, presented data indicating neurosurgeons continue to be the specialty that brings in the most profit for hospitals, although her data from 2003 is a bit dated.  She reported that their Trauma service is profitable.

  Item 2.  Dustin Corcoran from the CMA governmental affairs division gave an overview of what to expect from Sacramento and the initiative process in 2006.  He concurred with the death of the Vargas bill (see above) and felt that the Tobacco Initiative, now apparently proposing a new tax of $2.60/per pack on cigarettes would certainly benefit hospitals and heart, lung and cancer research to the tune of about 2 billion dollars/year.  Some of that funding would trickle down to some docs but neurosurgeons might see little help or at the worst, some reductions in coverage stipends.  The measure does allow hospitals to get a determination of the “fair and reasonable” price for ED coverage and impose it on docs.  This provision might be a bit less onerous than it appears since the limit on ED coverage doc payments could apply just to the Tobacco Initiative funds, leaving room for additional stipend amounts from the sources hospitals are now using to cover these on-call costs.  You can bank on the hospitals that use this avenue to state that the “fair and reasonable” price for ED coverage is the absolute take it or leave it ceiling.

Item 3.  John Kusske reiterated that the EMTALA law does mandate that if you are the neurosurgeon named as covering a hospital’s ED and your hospital has a bed, you must accept a patient referred from another institution if they declare themselves unable to provide emergency neurosurgical care.  This is apparently becoming an increasingly difficult avenue for referring hospitals with marginal or no neurosurgical coverage to pursue as receiving hospitals with 24/7 neurosurgical coverage are frequently full, requiring the referring hospital to shop far and wide to unload the patient.

Item 4.  The morning “ California ’s Crisis in Emergency Neurosurgical Care” session was kicked off by Mike Edwards reiterating the almost constant Stanford problem of having all available beds filled with EMTALA mandated transfers which impacts their ability to conduct their own elective neurosurgical cases.  He felt that if something isn’t done to improve general neurosurgical coverage of California ’s hospitals, the system is going to break down.  Bill Caton pointed out that recruiting good, young neurosurgeons to California is a real challenge. With reimbursement rates as low as they are, it becomes impossible to offer an income to these potential new neurosurgeons much greater than $250-300K (and that presumes a healthy stipend for ED coverage). This is a hard sell considering income guarantees in the Midwest and South are three times that number.  Apparently our sunshine and nearby ocean isn’t worth $500K.

The panel discussion among the directors of California ’s neurosurgical training programs was a study in a lot of talent under utilized.  Most of the California program directors were present.  We heard that the talent pool of applicants remains of high quality though the national number applying for the neurosurgical matching program is down from 350 in 2000 to 233 last year.  Of some concern is that women now comprise 64% of medical school students but only 9% of applicants for neurosurgical training potentially reflecting life style choices.  All the directors who were present expressed some concern about acting as the EMTALA mandated institutions of last resort, the bed crunch and that the future was not bright if we can’t attract new neurosurgeons to California since they can’t handle it all.  There wasn’t a clear message about how to deal with these problems, probably reflecting that a good solution can’t be identified even by these very bright people.

CANS wishes to acknowledge and thank the following companies who either exhibited or provided grants to defray some of the costs associated with the meeting:  Aloka Ultrasound, Anspach Companies, Baxter Healthcare, BrainLab, Endius, I-Flow, KLS-Martin, Medtronic, PDL BioPharma, Porex Surgical, Radionics, Synergy Medical, Synthes, TrueMRI and UCB Pharma.

3.  CANS—Message from the President: Transitions in Neurosurgery
January is the traditional month at our annual meeting when the changing of the guard occurs in CANS.  I am honored to be the 32nd President of CANS, and look forward to interacting, as much as possible, with all of you.  I would like to thank Mike Edwards for leading us so capably the last year, and hope to impose on his experience and advice over this coming year.

I must admit that I am very proud to be a neurological surgeon and I very much enjoyed active practice.  My current activity as a Medical Consultant to the State of California is certainly less demanding and less interesting, but I still consider myself to be a neurosurgeon and I intend to stay active in our specialty. 

Prior to the present newsletter editor, Randy Smith, I occupied that slot and contributed, at intervals, articles entitled “Transitions in Neurosurgery” which I intend to continue this year as President of CANS.  We are fortunate that Randy Smith has agreed to continue as newsletter editor.  I am grateful to him for this and we all recognize his characteristic style.

Neurosurgeons in California, CANS members and non-CANS members, face many challenges, including:   reimbursement issues, manpower (and woman power), emergency room coverage crisis, aging neurosurgery personnel pool, modes of practice controversy and conflicts with other specialties, and comp issues among others.  Quality of care issues are also paramount.

I hope to represent our profession and organization well, and am receptive to your comments and suggestions. I shall attempt to increase our membership numbers and leave an even stronger organization to the next President.

Many do not realize how fortunate we are to have such a competent and valued executive secretary in our CANS office, Janine Tash.  Our efforts and successes that may occur are greatly facilitated by her talents and dedication to our organization.  Working with her is a pleasure.
 John Bonner, M.D., F.A.C.S.

4.  CANS Officers for 2006  
John T. Bonner, MD, President, 559 431-1284 (home), 559 440-5081(work), rbonnerns@earthlink.net         
Patrick J. Wade, MD, President Elect, 818 247-0888, pjw7@earthlink.net
Moustapha Abou-Samra, MD, 1st Vice President, 805 643-2179, mabousamra@aol.com
William L. Caton III, MD, 2^nd Vice President, 626 793-8194 , wlciiimd@earthlink.net
Marc A. Vanefsky, MD, Secretary, 714 279-4958, marc.a.vanefsky@kp.org
Michael H. Robbins, MD, Treasurer, 916 453-0911,  mrobbmd@hotmail.com
Michael S. B. Edwards, MD, Immed Past Pres, 650 497-8775,  edwards9@stanford.edu                         
Alan T. Hunstock, MD,  Past President, 707 523-1873, hunstock@nbna.us 
Austin R. T. Colohan, MD,  Director-South,  909 558-4417, acolohan@ahs.llumc.edu  
Eldan Eichbaum, MD, Director-North, 707 523-1873,  eeichbaum@sbcglobal.net  
Deborah C. Henry, MD, Director-South, 714 279-4673, dchenry.md@sbcglobal.net  
J. Patrick Johnson, MD, Director-South, 310 423-9900, johnsonjp@cshs.org  
Theodore Kaczmar Jr., MD, Director-North,  831 424-0807, tedkazz@aol.com  
Kenneth Ott, MD, Director-South,  619 297-4481, kott@cts.com  
Kimberly Page, MD, Director-North, 530 246-2207, kimberlypage@sbcglobal.net  
                                                                                                                                                    John A. Kusske, MD, Consultant, 714 456-6966,  jkusske@uci.edu
Philipp M. Lippe, MD,  Consultant,  408 927-0802, pmlippe@att.net  
Donald J. Prolo, MD,  Consultant,    408 295-4022,  don@donaldprolo.com  
J. Ronald Rich, MD, Consultant, 310 315-3404, bayneurosurg@aol.com
Lawrence M. Shuer, MD, Consultant,  650 723-6093, lshuer@stanford.edu  
Randall W. Smith, MD, Consultant, 760 741-3809, rws-avopro@sbcglobal.net

The good news is this is a fine set of people to be representing CANS members.
The bad news is that Dr. Bonner has named me Newsletter editor for another year.

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.