Outcomes Certification and Reimbursement – NeuroLog Looms Large in the Future of Neurosurgical Residents

January 1, 2005

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For neurosurgeons currently in training, certification by the American Board of Neurological Surgery may be only a dot on the horizon while they attempt to survive the trials of residency. While they may have heard of outcomes evaluation, they probably have not yet participated in it. However, outcomes evaluation and how it presently relates to a neurosurgeon’s certification and reimbursement have become critically important issues which deserve attention during residency.

Neurosurgeons are certified by the ABNS after they pass a written examination during residency; then they must pass an oral examination taken after being licensed to practice and accumulating one year of practice data for board review. The ABNS also requires neurosurgeons certified in 1999 and after to be recertified every 10 years through its Maintenance of Certification program.

The MOC program has several components, among them submission of key cases and a surgical case log that is identical to the case log submitted for the oral examination. To help neurosurgeons prepare for their initial certification as well as for MOC, the ABNS developed NeuroLog, a database accessed through the Internet. Designed for practice assessment, NeuroLog standardized the submission format for case data and outcomes evaluation by utilizing Current Procedural Terminology codes.

NeuroLog also tracks residents’ case participation for individual evaluation, and it can be used to develop summaries for neurosurgical program directors and provide the Residency Review Committee with accreditation statistics. NeuroLog represents a significant development in database management and outcomes assessment for all neurosurgeons. It also represents an extension of traditional outcomes assessment via internal review conferences.

Such conferences address morbidity and mortality and foster discussion of difficult cases and suboptimal outcomes. Conference participants can benefit from the variety of perspectives and turn all-too-human mistakes to the benefit of future patients. Now, as the outcomes review process is quantified, the ramifications extend beyond training and improved patient care to reimbursement for physician services.

Pay-for-performance programs are the newest trend in healthcare administration. Some programs quantify subjective variables such as patient satisfaction, return-to-work times, and willingness to adopt new techniques, and offer financial incentives for physicians who meet the criteria. For example, an article in the February 2005 issue of Physicians Practice reported that Blue Cross expected to pay a $3,500 bonus to an “average-performing” physician, and up to $12,000 to its “highest performing” physicians. Advocates of P4P programs believe that they encourage physicians to perform their best and allow patients and insurers to identify the safest and most successful doctors. For most neurosurgeons the basic idea of being rewarded for a job well done is probably appealing. However, three main concerns spring to mind.

First, will P4P programs discourage physicians from performing complex procedures or treating the sickest patients? Since patients who have had multiple operations and complicated surgeries are considered more likely than others to sustain complications and stay in the hospital longer, it seems likely that physicians treating them would be “rewarded” with poorer performance ratings and lower reimbursement. If the P4P initiatives penalize physicians who treat difficult cases, would these programs incentivize physicians to refer out all but the simplest of cases? Under such a system, who would treat the basilar apex aneurysms, the failed cervical or lumbar fusions, or the traumatic injuries?

Second, who will have access to outcomes data? Because they directly result from patient safety and quality of care concerns, P4P programs are intended to improve patient outcomes, a goal all neurosurgeons share. However, the physician performance data in the public domain and could have a detrimental effect on medicine. For example, political or legal entities might use the data to set a local “standard of care” which may or may not be related to standards determined by medical professionals.

Third, will P4P be an excuse for some payers to reduce reimbursement? Medicare is the most influential payer to announce a P4P initiative because Medicare’s reimbursement rates are the benchmark used by other insurance providers. For example, an insurer may reimburse at 110 percent of the Medicare rate and another, at 85 percent. If private payers parallel Medicare in lowering reimbursement but do not also adopt a performance bonus, physician reimbursement would decrease.

The ABNS developed NeuroLog to assist residents with transition to board certification and outcomes assessment over the course of their careers. NeuroLog, an excellent tool for providing data and insight that can help a neurosurgeon improve care for patients, is a work in progress which will evolve as the need for specific outcomes data is clarified. The benefits of P4P initiatives are less certain, but neurosurgeons can expect to feel the impact of P4P programs as early as 2006.

Brian R. Subach, MD, FACS, is a neurosurgeon at The Virginia Spine Institute, Reston, Va.

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