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| Fremont P. Wirth MD |
Operating from a position of organizational strength allows us to enhance activities that support the AANS’ leadership role in the multitude of issues affecting neurosurgery. We as individual neurosurgeons also need to become much more involved in many areas. If the AANS is to succeed in influencing these issues, your individual help will be essential.
Access to neurosurgical care will in all probability become a problem for many of our patients in the coming years unless we can positively influence three very difficult issues: medical liability reform, physician reimbursement and neurosurgical workforce efficiency. Successfully influencing the resolution of any one of these issues by itself is a daunting task, but all three must be addressed simultaneously. I would like to update you on our progress and future plans with respect to these concerns.
Optimizing Support for Medical Liability Reform
This past year Neurosurgeons to Preserve Health Care Access, under the able leadership of John Popp, MD, contributed $1 million to Doctors for Medical Liability Reform. You may recall that the successes of the DMLR’s Protect Patients Now public education campaign were delineated in the Spring 2005 issue of the Bulletin.
To capitalize on the DMLR campaign’s successes and to optimize neurosurgery’s support for federal medical liability reform, this summer the AANS organized a new political action committee known as AANSPAC. This new PAC, which will focus on promoting the election to the U.S. Congress of candidates who support medical liability reform, is now fully operational under the leadership of Chair Gary Bloomgarden, MD, Vice-Chair Lyal Leibrock, MD, and Treasurer Jim Bean, MD. The AANSPAC is aligned with your elected AANS officers and directors to assure that it will be responsive to the needs of neurosurgery as you define them. Most of the former PAC’s board members form the board of AANSPAC, and Katie Orrico continues her effective and energetic efforts on behalf of neurosurgery in our Washington office. The AANS/CNS Washington Committee and the Council of State Neurosurgical Societies are represented on the AANSPAC board, as is DMLR.
Although the new PAC will not be able to accept contributions from corporations or university departments, a major benefit of the new structure is the streamlined process for making contributions. Because contributions can be solicited from voting or dues paying AANS members with the dues invoice, donating to AANSPAC will be a simple and efficient process.
However, there remains a major problem with our efforts for liability reform. In the first six months of 2005, only 392 members — about 6 percent of AANS membership — contributed to medical liability reform via NPHCA. I find this to be an astonishingly poor response to what is one of our most pressing issues! We have to do much better if we are to have an impact in Washington. Members of other associations such as trial lawyers and chiropractors support their legislative agendas almost universally. Additional information about AANSPAC and NPHCA accompanies this article.
Influencing Physician Reimbursement
If liability reform seems challenging, influencing physician reimbursement is even more difficult because of the budgetary constraints placed on Medicare, the federal program that so powerfully influences all reimbursement issues. Neurosurgery, along with many other specialties, faces a 4.3 percent cut in fees in the coming months unless the sustainable growth rate formula used in the calculation of Medicare reimbursement is replaced by a more realistic formula that recognizes medical economic conditions. Legislation addressing this issue has been proposed in both the U.S. House of Representatives and the Senate. This legislation deserves your scrutiny. You should also be aware of the pay-for-performance movement, which is supported by both the private sector and the government. This so-called P4P initiative is based on the laudable concept that good medical care should be rewarded. However, how this concept will be measured and applied to procedural physicians such as surgeons has not been worked out. There are models in other countries, and demonstration projects are underway in this country. It appears that implementation of some form of this concept is inevitable. The AANS currently is working with the American College of Surgeons and the American Medical Association to ensure that the interests of neurosurgeons and their patients are protected through the use of appropriate quality measures to evaluate care.
Evidence suggests that patients’ access to care already is being limited by declining reimbursement from Medicare and Medicaid. Recent data reported in the Medical Association of Georgia Journal indicates that access to care has decreased in Georgia. In 2000, 85.4 percent of Georgia physicians were accepting Medicaid patients, and in 2004 only 77.3 percent were doing so. For Medicare the numbers were almost the same, down from 85.4 percent in 2000, to 78.3 percent in 2004. This is a disturbing trend and I doubt it is unique to Georgia. The Washington Committee and our legislative liaisons need our individual support. We need to contact our senators and representatives on these issues. It is our obligation to become informed and involved. No one else will do it for us or for our patients.
Supporting Medical Liability Reform
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The third issue we face as neurosurgeons is a decreasing workforce. Given the growth of our population, increasing longevity and the increasing number of surgical remedies we can offer, neurosurgery would be challenged if its numbers were static. That, however, appears not to be the case. Again, data from Georgia reveal that neurosurgeons per 100,000 population have fallen from 1.59 in 1992 to 1.39 in 2002. Reliable national data are more difficult to obtain, but in other areas of the country this decline in the numbers of neurosurgeons appears to be the case as well. Indeed, Tom Origitano, MD, writing in the Summer 2005 issue of the Bulletin, reported rates of 1 neurosurgeon per 350,000 population for cranial cases in the Chicago area. The recent Council on Graduate Medical Education’s 16th Report cites several possible causes for the expected shortage of physicians, including early retirement, “quality of life” issues exemplified by physicians who elect to work shorter hours or take more time off, and shorter resident work hours, which potentially alter expectations for work hours in the future. As I am sure you are also aware, many neurosurgeons are restricting their privileges, most often giving up intracranial work, with the expectation of decreased call responsibilities and decreased liability exposure. The further restriction this imposes on access to care for patients is obvious. Interestingly, if the data from The Doctor’s Company summarized by Richard Wohns, MD, in the Summer 2005 issue of the Bulletin is correct, rather than decreasing liability exposure, forgoing intracranial procedures in favor of spinal procedures actually may increase it.
These problems have not escaped the attention of our general surgery colleagues. The development of a “Board of Acute Surgery” has been suggested as one means of alleviating the shortage of specialty physicians available for emergency care. As inappropriate as this may seem, a solution will have to be found for the increasing societal need for neurosurgical services. I for one feel that our patients will suffer if we relegate their care to physicians who are not fully trained in the surgical management of the nervous system. Neurosurgery also will suffer if we fail to develop a system of neurosurgical care delivery that does not disproportionately overburden our academic and other large neurosurgical centers with an excess of high acuity, poorly reimbursed patients. To address this issue, the AANS has formed a task force of respected neurosurgical leaders representing a broad cross section of our specialty to study possible solutions for this vexing dilemma.
In the coming months I anticipate that many of you will be called upon to contribute some of your time, energy and intellect by responding to surveys that seek new information to broaden our database of neurosurgical practice, needs and expectations. For example, your participation in two surveys this fall, the second annual NERVES Neurosurgery Practice Survey (see cover story) and the AANS census (www.MyAANS.org) will provide important information about the neurosurgical workforce and how neurosurgeons are practicing today. Your support and assistance with these projects and others will be invaluable as we address the many important issues affecting neurosurgery.
Fremont P. Wirth, MD, is the 2005-2006 AANS president. He is in private practice at the Neurological Institute of Savannah in Georgia.<