The interim report from the AANS/CNS Task Force on Fellowships was the featured presentation at the Council of State Neurosurgical Societies (CSNS) September meeting held in New Orleans. The Council heard an update from the Washington Committee on the Medicare practice expense adjustment, the effects of the 1997 Balanced Budget Act, and the federal enforcement of evaluation and management documentation guidelines. Robert Harbaugh, MD, chairman of the Outcomes Committee of the Joint Committee on Assessment of Quality (JCAO), reported on the reorganization of the committee and new outcomes measurement instruments adopted for carotid and aneurysm surgery. The Council also acted on seven resolutions.
Task Force on Fellowships
The CSNS approved a resolution in April 1997 requesting appointment by the Joint Officers of a Task Force on Fellowships to “examine the issues surrounding minimum standards for maintaining the quality of fellowship training programs.” The Task Force, appointed in April, includes Julian Hoff, MD (chairman), James Bean, MD, Hunt Batjer, MD, Frederick Boop, MD, (Vice-chair), Kim Burchiel, MD, Stewart Dunsker, MD, Steven Haines, MD, and David Jimenez, MD. After two teleconferences and background research on the prevalence of fellowship training, several resident and fellow surveys, and information on fellowship training in other specialities, the Task Force reached preliminary conclusions. Dr. Boop presented a summary of the Task Force’s background information and preliminary recommendations to the CSNS lunch session Saturday, September 27. Dr. Jimenez presented an updated survey of neurosurgeons who have recently taken fellowships. Preliminary Task Force conclusions and recommendations included: 1) a definition of fellowships, 2) Joint Section development of fellowship program criteria, 3) fellowship program accreditation, 4) fellowship affiliation with an institution sponsoring an ACGME-approved training program, and 5) certification of completion of fellowships by sponsoring institutions, without ABNS subspecialty certification. Task Force members presented individual viewpoints to the CSNS audience and listened to comments, criticisms, and concerns from CSNS members to guide final recommendations to be made to the AANS/CNS Joint Officers in January, 1998.
Resolutions — The CSNS Reviewed and Acted on the Following resolutions:
Expert Witness File
The Council urged wider notification of AANS/CNS members of the existence of the Expert Witness File. A resolution passed requesting periodic publication of the existence of the file in the AANS Bulletin, the CNS Newsletter, the Socioeconomic Section of NEUROSURGERY://ON-CALL®, the Journal of Neurosurgery and Neurosurgery.
The Expert Witness File contains plaintiff deposition testimony given by expert witnesses who have testified in past neurosurgical malpractice actions. The file is available via attorney to attorney request from the AANS office. The purpose of the file is provide information to malpractice defense attorneys regarding neurosurgical expert witnesses who testify repeatedly against neurosurgeons and the character of the past testimony.
Peer Review Guidelines
A resolution asked for the identification of guidelines for local institutional peer review regarding indicators of competence for performing aneurysm surgery. The request was referred to committee for report. The unavailability of information on general competency guidelines or of standardized outcome data for peer review of neurosurgeons prevented direct action.
Unions and Neurosurgery
Unionization of doctors for negotiating power has appeared in reports scattered from New England to Florida to Arizona. The New England Neurosurgical Society requested a report on the practicality and implications of neurosurgeons forming or joining unions. The report will be returned to the Council in April 1998.
Delay in Board Certification
Neurosurgeons recently completing residencies have experienced problems contracting with managed care organization (MCO’s), which require board certification as a credentialing criterion. The problem stems from the interval between completion of residency and board certification caused by the American Board of Neurological Surgery (ABNS) requirements for one year of practice data, 3 months follow-up, submission of cases; and a backlog of applications for the oral board examination. An interval of 3 years or more is common between completion of residency and board certification.
The number of MCOs adhering to the policy and the number of newly practicing neurosurgeons affected is not yet known, but the problem appears to be common and growing according to anecdotal reports heard by the CSNS. The Council approved a resolution requesting the AANS and CNS to support action by the ABNS to resolve the problem created by the delay in certification. The Young Physicians Committee of the CSNS will collect survey data documenting the extent and severity of the problem.
Case rate malpractice defense
The Council approved a motion to alert all AANS and CNS members to a method of malpractice legal defense reimbursement currently employed on a trial basis by the Doctors’ Company in California. The program is termed the Progressive Litigation Program (PLP), and pays the defense legal firm at a predetermined fee for each phase of the litigation (discovery, pretrial, and trial phases), rather than on a fee for service basis. Proposers of the resolution expressed concern that a defense attorney may not be motivated to expend maximum necessary effort in physician defense if the stipulated fee is fixed. The payment method was compared to fixed case rates or capitation rate payment for surgeons. The trial program currently exists only in California, but the resolution was approved to alert all neurosurgeons to be aware of their malpractice carrier’s legal reimbursement methodology.
Medicare Private Contracting
The Federal Balanced Budget Act of 1997 (passed in August) included a provision allowing private contracting between a physician and a Medicare-eligible patient. However, the physician electing the private contracting option must submit an affidavit to the Health Care Financing Administration (HCFA) agreeing to be excluded from participation in the Medicare program for 2 years.
The initial provision by Senator Kyl of Arizona aimed to remedy restrictions under Medicare law on balanced billing and a citizen’s right to privately contract. The addition of the 2-year Medicare program exclusion was added in a late legislative compromise. The Council approved a resolution supporting proposed legislation to repeal the 2-year exclusion provision.
Neurosurgery Capitation Rates
The Council approved a request for the AANS and CNS to explore means for making information on regional neurosurgical capitation rates available to their members. Although accurate estimation of a capitation rate requires health plan specific data and knowledge of practice costs, the request for regional information was made to help neurosurgeons who are first encountering specialty capitation.
Implementation of the request will require legal opinion regarding the antitrust implication of providing pricing information to members, determination of the cost of acquiring third party actuarial information, and the cost to a member for capitation information provided at a discount from a third party actuary.