AANS Neurosurgeon | Volume 28, Number 4, 2019


Do Not Go Gently

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“Do Not Go Gently…”
-Dylan Thomas

Boop, Frederick With the implementation of the Affordable Care Act (ACA) in 2010 came a new model for reimbursing physicians, which is predicated upon networks of physicians and hospitals working together to share responsibility for providing care to Medicare patients in ways that would curtail spending while improving the quality of patient care and the patient’s health care experience. The term Accountable Care Organization (ACO) was first introduced in 2006 by Dartmouth professor Elliott Fisher as a futuristic program for health care reform that hoped to eliminate some of the shortcomings of fee-for-service and other earlier payment and health care delivery models designed to reign in Medicare spending (1). Given that lawmakers had a mandate to reduce the national deficit, Medicare spending was a primary target. As baby boomers approached retirement age, serious concerns loomed that their entry into the Medicare program could significantly challenge the program’s viability. Alternatively, early modeling by the U.S. Department of Health and Human Services (HHS) suggested that implementing ACOs could save the program as much as $960 million in three years (2).

In traditional fee-for-service medicine, the more services physicians provide, the more money physicians will make. In the proposed ACO model, fee-for-service medicine would not be eliminated; however, the model would incentivize cost savings, streamline treatment and achieve quality benchmarks. The ACO would be provider-led and, over time, would lead to progressively more sophisticated coordinated care, reducing both numbers of hospital admissions and readmission rates.

Been There Before
We have all lived through previous iterations of health-care reform. For physicians, the first major overhaul was the adoption of the Resource-based Relative Value Scale (RBRVS) by Medicare. Implemented in 1992, instead of basing payments on charges, this system set an overall global budget for Medicare Part B physician spending, and payments for services are determined by the resource costs needed to provide them. Soon thereafter, in 1997, the sustainable growth rate (SGR) payment formula was introduced. Its goal was to limit further growth in physician spending . Unfortunately, the SGR methodology was significantly flawed and, beginning in 2002, it required steep annual cuts in physician payments — although, because of significant political pressures, Congress repeatedly prevented the implementation of these unpalatable fee cuts. Ultimately, the annual ritual of overriding these cuts — which would have reduced Medicare payments to physicians by over 20 percent — came from a federal budgetary standpoint, and Congress passed the Medicare Access and CHIP Reauthorization Act (MACRA), which repealed the SGR and replaced this formula with a new quality-based payment model. It took nearly two decades of negotiations to pass this SGR repeal law, and the jury is still out as to whether the new system will improve quality and decrease health-care costs. 

The 1990’s also saw the proliferation of Managed Care Organizations (MCOs), whose purpose was also to limit health care expenditures. These Health Maintenance Organizations (HMOs) introduced new concepts, such as patient co-payments for services, closed provider panels, the utilization of so-called “gatekeepers” who controlled referrals to specialty care, pre-authorization of services, etc. Physicians and patients continue to struggle with these same concepts today. Capitated service contracts introduced the concept of risk sharing but fell short of the ACO model in that they encouraged providers to control spending without addressing the quality side of the equation. Thus, in the newer model, ACOs evolved to share risk between payors and providers, yet, unlike MCOs, providers are held accountable for quality metrics as well as cost containment (3).

ACOs and Neurosurgery
The ACO model has proven to work in pilot projects in which primary care measures, such as beta-blockers for myocardial infarction patients or aggressive glucose control for diabetics, have been implemented. We recognize that a small percentage of very sick, high-risk patients, such as those neurosurgeons typically care for, account for the majority of health-care spending (4). Although these patients present some challenges, the development of proper metrics for neurosurgical patients could result in substantial cost savings, limit futile care and improve quality. Challenges include how “productivity” would be measured in a small, high-end subspecialty. Whereas at present, we are paid primarily by volume, the ACO neurosurgeon will be paid based upon 1. evidence that the operation is necessary and 2. the operation is performed in a high-quality and cost-effective fashion.

The ACO neurosurgeon will also face a number of new threats. Working in an ACO model will necessitate increased oversight and regulations as practice parameters and costs will be reported for each patient encounter, and the physician will be held accountable not only for quality metrics but also for patient reported outcomes and satisfaction. Furthermore, time devoted to service on committees and interacting with administrators will be time away from patient care, continuing education, research and family. 

Role of the AANS
Since its inception, organized neurosurgery has enjoyed a presence far beyond its size. No less so than today. The American Association of Neurological Surgeons (AANS)/Congress of Neurological Surgeons (CNS) Washington Committee, chaired by Shelly D. Timmons, MD, PhD, FAANS, works tirelessly to make neurosurgery’s presence known inside Washington, D.C., and has played a significant role in moving legislation through Congress — as witnessed by the recent repeal of the SGR. Some examples include:

  • Working through the Alliance of Specialty Medicine — which was founded by our Washington office director, Katie O. Orrico, JD, and others — smaller subspecialty groups, such as ours, continue to work together to amplify our voice.
  • Volunteer neurosurgeons, such as those working on the AANS/CNS Neurosurgery Quality Council (NQC), which is chaired by John K. Ratliff, MD, FAANS, have helped develop, validate and implement quality measures meaningful to our specialty.
  • The AANS/CNS Joint Guidelines Committee (JGC), chaired by Kevin M. Cockroft, MD, FAANS, continues to produce and update evidence-based guidelines, which not only help define appropriate care but also point out where new efforts are needed.
  • Our many neurosurgery representatives to the American Medical Association (AMA)/Specialty Society Relative Value Scale Update Committee (RUC), AMA CPT Editorial Panel and the AANS/CNS Coding and Reimbursement Committee’s Rapid Response Teams, work tireless throughout the year to ensure fair reimbursement for the services provided by neurosurgeons.
  • NeurosurgeryPAC, our political action committee, continues to ensure that we have a strong voice on Capitol Hill by backing candidates who will champion our issues and move our legislative agenda forward for the betterment of practicing neurosurgeons and their patients.
  • NeuroPoint Alliance (NPA) and its Quality Outcomes Database (QOD) — our national prospective outcomes registry — now has over 80 centers participating, with over 30,000 patients enrolled in the spine module, over 400 in the Stereotactic Radiosurgery (SRS) module and a new initiative underway with the American Academy of Physical Medicine and Rehabilitation (AAPM&R) to tabulate detailed observational data, including patient-reported outcomes, with the intent of developing risk-adjusted, population-specific benchmarks.
  • The Neurosurgical Research and Education Foundation (NREF) continues to fund research and educational opportunities for both young and mid-level practitioners. Funding not only basic science grants and fellowships but also targeted clinical research, such as comparative effectiveness paradigms, requires ongoing commitments from each of our members

As stated by President John F. Kennedy, “Change is the law of life. And those who look only to the past or present are certain to miss the future.” Neurosurgery faces many challenging times ahead with the rapid changes occurring in the health care delivery system. As the specialty navigates the choppy waters of the future, we must be informed by the past and present but must also adapt to the evolving care delivery models. While we comprise less than 1 percent of the health-care pyramid, neurosurgeons enjoy a respectable presence because of the continued efforts of our professional societies and our members who give selflessly to ensure that our patients continue to have access to the best care we can provide. Because of this commitment and our unique place in the health care continuum, I am confident that neurosurgery will continue to thrive well into the future!

1. ACO Learning Network Available at: https://acolearningnetwork.org.

2. McWilliams JM, Hatfield LA, Chernew, MD, Landon, BE, Schwartz AL. Early performance of accountable care organizations in Medicare. N Eng J Med. 2016 Apr 13. [Epub ahead of print] PMID: 27075832

3. Goodney P, Fisher EX, Cambria RP. Roles for specialty societies and vascular surgeons in accountable care organizations. J Vasc Surg. 2012 Mar: 55(3); 875-882

4. Powers BW, Chaguturu SK. ACOs and high-cost patients. Engl J Med 2016; 374:203-205; January 21, 2016

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