In summer 1995, The American Association of Neurological Surgeons (AANS) and the Congress of Neurological Surgeons (CNS) joined together to conduct a comprehensive study of neurosurgical practice in the United States. In the past, the practice survey as done every five years, However, the movement away from traditional fee-for-service medicine has caused unprecedented changes in health care during the last few years. So, to gauge the amount of change that has occurred in neurosurgery practices, the survey was done three years following the 1992 survey and two years ahead of schedule.
Data collected from the 1992 survey was used to benchmark the 1995 survey results, measuring the changes that continue to occur in the health care environment. Comparisons were also made to data collected in the 1987 Comprehensive Survey.
The survey instrument was designed, jointly, by the Gary Siegel Organization, Inc. and Byron Pevehouse, MD. The questionnaire was divided into four parts:
- Current practice status.
- Biographical information concerning medical school, residency and fellowship training, specialty certification, membership in professional organizations, etc.
- General practice questions, including questions on prepaid and contractual agreements, practice activities and patient profiles, revenues and expenses, and professional liability.
- Frequency and type of office services and surgical procedures, fee and payment questions.
This report contains highlights from key sections of the survey judged to be of greatest overall interest to neurosurgeons. More detailed information can be found in the 460-page survey report, 1995 Comprehensive Neurosurgical Practice Survey . AANS and CNS members who participated in the survey automatically received copies of the report. Non-participants may order single copies of the report from the AANS Order Fulfillment Department at the National Office. The cost to members is $125; non-member physicians may purchase copies for $195 and institutions /corporations can order the report for $300.
Methodology
The universe, for purposes of this study, was all neurosurgeons with valid profes sional mailing addresses in the United States as defined by the AANS and CNS membership records, the American Medical Association (AMA) masterfile of physi cians, and registrants for the AANS/CNS annual meetings who identified themselves as neurosurgeons. Residents in-training were excluded.
A total of 4,003 questionnaires were mailed in May 1995 to neurosurgeons with a practice or residential address in the United States and Puerto Rico, requesting personal and practice information for the 12 month period of fiscal year 1994. For the majority, the time frame was the calendar year 1994, but could also have been as recent as December 1, 1994 to November 30, 1995.
By the end of November, 1,423 questionnaires were returned. Of these, 1,421 were judged sufficiently completed to be acceptable for the study, representing a response rate of 36 percent of the universe.
Geographical and Age Distribution of Neurosurgeons
There has been relatively little change over the past five years in terms of practice location. As in 1987 and 1992, the largest percentage of respondents practice in California (11.3%). The 1995 results show that California is followed by Texas (8.2%), New York (7%), Florida (6.1%), Pennsylvania (5%), Illinois (3.8%) in terms of numbers of neurosurgeons. More than 41% of the respondents practiced in these six states.
A plurality of respondents (34%) practice in metropolitan areas with a population in excess of one million. In contrast, cities and towns with a population under 50,000 are home to just 6.9% of respondents’ practices.
Based on our estimate of the U.S. population of neurosurgeons, there are approximately 15.2 neurosurgeons per 1 million population. This number is up slightly from 1987, when there were 14.7 neurosurgeons per million but less than the estimate of 16.3 neurosurgeons per million in the 1992 comprehensive survey.
The mean age of respondents in 1995 was 49.6 years; in 1992 the mean age of respondents was 49.8 years, and in 1987 the mean age was 48 years.
Professional Activity and Practice Characteristics
This section of the survey includes information on a wide array of practice characteris tics: the mode of practice, legal structure of the practice, years in practices, size of practice, subspecialization, patient characteristics, and membership in professional associations.
The majority of respondents (69.6%) are engaged in the full-time private practice of neurosurgery. Of the rest, 15.4% are engaged in a combination of clinical neurosurgery, teaching, administration and research.
In terms of practice setting, 69.5% of respondents report their principal work organization to be a private office neurosurgical practice, 19.2% report it to be a medical school or university, and 6.6% report it to be a hospital, foundation, or other institution, all showing minimal difference from 1987 and 1992.
Nearly 46% of respondents in private practice work in solo practices, 42.2% practice as part of a neurosurgical group, 8.6% are in a combined neurosurgery /neurology group practice, and 3.4% are in a multi-specialty group. In 1995, younger respondents show a distinct tendency to practice in a neurosurgical group as compared to those above age 55 who are predominately in solo practice.
In the years from 1987 to 1992 there was an increase in the limitation of practice to a subspecialty from 11.3% to 16.1% of responding neurosurgeons. In 1995, only 15.9% limit practice to a special interest, predominantly in large communities. (See Figure 1.)
Self-designated Subspecialty Interest
1992, 1995
1992 1995
Number Percent Number Percent
ALL RESPONDENTS 213 100.0 175 100.0
SUBSPECIALTY
Spinal surgery 76 35.7 64 36.6
Neurosurgical Oncology 26 12.2 8 4.6
Pediatric 70 32.9 54 30.9
Stereotactic/Brain Tumors 17 8.0 6 3.4
Pain/Trauma 10 4.7 5 2.9
Vascular 3 1.4 10 5.7
Cerebrovascular 6 2.8 12 6.9
Epilepsy 5 2.3 3 1.7
Neurology 2 1.1
Skull Base 8 4.6
Peripheral Nerve 3 1.7
NUMBER OF RESPONDENTS
1992 213
1995 175
In 1992, 48.4% of respondents were either too busy to accept all new patients or felt that they worked too much. In 1995, that number decreased to 41.9%. A plurality of 1995 respondents (43.8%) accept all appointments and referrals and feel that they have the right amount of work. In contrast, 14.3% would like to see more patients, compared to 9.4% in 1992.
In terms of surgical work, 66.0% of respondents perform between 3 and 6 operations per week. The mean is 5.0, compared to 5.3 in 1992. Slightly more than 34.4% of respondents feel that they have the right amount of surgical work and accept all patients, 35.4% have time for more surgical volume, and 24.9% accept all surgery patients, but work more hours than they would like. There was little difference in the 1987, 1992 and 1995 responses to this questions.
Manpower and Competition
Respondents were asked to describe the number of neurosurgeons in their practice community relative to the number of patients needing neurosurgical care. Fifty percent think that there are the right number of neurosurgeons currently in practice; 45 % feel that there are too many neurosurgeons in practice, and 5% say there are not enough. This represents a significant change since 1992 when the percentages were 56%, 34% and 9% respectively. These opinions differ based on size of practice community, location of practice and mode of practice.
Respondents were asked about competition levels between neurosurgeons and orthopedic surgeons compared to five years ago. Sixty-seven percent feel that there is more competition between neurosurgeons and orthopedic surgeons than there was five years ago, while 27% feel that competition has remained the same. These opinions also differ, based on size of the practice community, location of practice and mode of practice. In 1995, respondents in cities with populations between one and two million are most likely to perceive competition as increasing.
Managed Care
In terms of relationships with various health care organizations, 90.8% of respondents in full-time private practice maintain contractual agreements with an HMO, IPA or PPO. The percent of respondents that have these agreements differ slightly based on the mode, legal structure and geographic location of the practice. (See Figure 2.)
Respondents were asked about the impact of managed care and its policies, over the preceding three years, on the volume of services and procedures they provide. For example, 27% of respondents state that exclusion from managed care network contracts has caused a decrease in practice volume while 36% reported there was no change. For those who are part of managed care networks, 35.2% reported increased volume, while 52.3% said there was no change. Finally, those in networks said that they experienced a 17.5% increase in gatekeeper referrals, while 48.2% reported no change.
Medicare Participation
From the time of the 1987 survey, through 1995, the number of physicians participat ing in Medicare rose significantly. Whereas 50% of respondents were participating physicians in Medicare programs in 1987, 90% are participating physicians in 1995.
The average charge in 1995 for a new patient consultation (Medicare patient) was $190, while the average allowable payment was $134. Nearly 79% of respondents in full-time private practice reported reduced reimbursement after the 1992 implementation of the Medicare Fee Schedule. State level changes in Medicaid fees resulted in reimbursement decreases for 65.2% of respondents. In addition, 83.3% reported lower reimbursement rates due to managed care payment arrangements and discounts.
Patient Fees and Source of Patients
Respondents say that most of their patients are referred by other physicians, followed by contractual agreements and by referral from other patients.
Sources of payment for neurosurgical services has significantly changed during the eight years from 1987 to 1995. “Private pay” (from the patient or personal insurance policy) has decreased from 42.4% to 27.4%, while prepaid and contractual payments have increased from 12.9% to 21.6%. Workers’ compensation and Medicare have remained fairly stable at about 20% each. Medicaid has increased from 6.9% to 9.6% of total revenue.
Lumbar/thoracic spine problems continue to be the most common condition seen by neurosurgeons.
In 1995, 89% of respondents reported they provide free care to indigent persons. That is down slightly from 1992, when 93% of doctors reported they provide free care. The overwhelming majority (90%) of indigent patients are referred by another doctor or come into the emergency room. The mean estimated dollar value of free care provided to indigent persons by 1995 respondents amounts to $70,200 per neurosurgeon.
Professional Liability Insurance and Malpractice Claims
Ninety-four percent of respondents reported that their hospitals required professional liability insurance of specified limits for medical staff appointments. However, 6.6% of 1,212 respondents did not carry professional liability insurance and a majority had been “bare” for a significant number of years.
The most common form of liability insurance carried by respondents is physician owned insurance, as reported by 54.7%. Fifty percent report carrying liability coverage from a commercial insurance company, and 20.8% are covered by institutional self-insurance/off-shore trust.
The mean annual premium for liability insurance for all respondents was $41,400, no significant change from 1992. The mean amount of basic coverage per policy year for all respondents was $2,470,000 and the mean limit per claim for all respondents was $1,496,000. Nearly 36% of respondents had excess limits (umbrella) coverage. The amount of umbrella coverage above basic policy limits was an average $3,247,000 for all respondents who had such coverage.
The number of malpractice claims were up slightly in 1994 (0.44 claims per respondent) from 0.31 claims per respondent in 1993 and up 0.2-in each of the previous six years.
Professional Revenue and Net Income
Ninety-one percent of the respondents report that the majority of revenue for neurosurgical services is derived from surgical practice, with 48% stating that more than 75% of revenue and 43% state that 51% to 75% of revenue comes from surgical practice. Distribution of revenue generated from various types of neurosurgical services changed little between the 1987, 1992, or 1995 surveys. (See Figure 3.)
Figure 3
1987 1992 1995 Surgical Practice 75% 71% 72% Office-Based Services 19% 21% 20% Diagnostic Services 6% 4% 3% Medical-Legal Work 4% 5% 3%
Between 1987 and 1992 there was little change in the distribution of payment sources for
neurosurgical services. Private (self or insurance) was the principal source of payments. This changed in the 1995 survey, with prepaid and contractual agreements becoming a significant portion of gross revenue for neurosurgeons in private practice settings. (See Figure 4.)
Figure 4
1987 1992 1995 Patient Payment 8% 8% 8% Blue Cross/Blue Shield 19% 17% 14% Other Private Insurance 26% 29% 23% Medicare 19% 19% 20% Medicaid 6% 7% 6% Workers’ Compensation 19% 20% 19% Pre-paid Contracts 7% 11% 12% PPO Contracts 4% 9% 10%
In 1995, mean net income as reported by respondents in full-time private practice increased 11% as compared to 1992 and increased 57% as compared to the 1987 survey. However, there was great variation according to geographic location of practice, with New England and Pacific Coast areas reporting marked decreases. In 1995, 39% of respondents indicated a greater than 10% decrease in net income, while 21% indicated a greater than 10% increase in net income, mean average in the U.S.
Gatekeeper Referrals
Physicians were asked about the number and percentage of respondents’ referral patients who required managed care primary care gatekeeper authorization. The plurality (23%) reported that 21-49% of all their referral patients required gatekeeper authorization.
When asked about six possible outcomes of gatekeeper referrals, the least -occurring effect (6%) is over-involvement of the gatekeeper after referral.
Gatekeeper Referrals Which Affected Outcome for Patients
(Neurosurgeons in Full-Time Private Practice)
Number Mean % Median % Inappropriate timing of referral 494 10.5 5.0 Lack of referral to the appropriate specialist 484 7.4 3.0 Over-involvement of the gatekeeper after referral 445 5.5 0.0 Under-involvement of the gatekeeper after referral 449 9.3 1.0 Misdiagnosis of patient by gatekeeper 472 8.7 5.0 Improper care provided by gatekeeper 457 7.8 1.0
Finally, respondents were asked what they see as the major challenges facing the neurosurgical specialty in the next two to three years. The most frequent responses were the development of managed care, competition with orthopedic surgeons, oversupply of neurosurgeons, and decrease in reimbursement.