CANS NEWSLETTER—Oct 2006
1.
New Work Comp Surgeon’s Fee
Schedule
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
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
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
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
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.
Transitions
in Neurosurgery: Capitalizing on the
¨
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.
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
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
c.
CMA & AANS Get New Leadership
Jack Lewin, M.D., left his post as CMA CEO to take over the
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
d.
State Council Resolutions
At the Council of State Neurosurgical Societies recent meeting in
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
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.