As this is written, three months have passed since I assumed the presidency of the AANS. They have been three very busy months, filled with travel, meetings and — frequently — enlightenment. During this time, I have been both gratified and amazed at the dedication that your leadership has shown in representing organized neurosurgery. The breadth and depth of what they do never ceases to astonish me. That’s why I’d like to share with you a bit of what of we all have been up to the past few months.
Neurosurgical Society of America
Immediately following the AANS meeting in Minneapolis, Immediate-Past President Sidney Tolchin, MD, Secretary Martin Weiss, MD, and I were invited to participate in a Workforce Symposium at the 1996 Annual Meeting of the Neurosurgical Society of America in Laguna Beach, California. In particular, we discussed the quality of resident training and the neurosurgical workforce.
The discussions were both constructive and extensive and I found it encouraging that these issues were the focus of the opening session at a scientific assembly.
Washington Committee
The AANS/CNS Joint Washington Committee met May 30-31 in Washington, DC. Our discussions covered a broad range of topics including reimbursement issues and biomedical research.
One of the issues that we have been focusing on lately is the reimbursement for pallidotomy. Unfortunately, there is no national uniform payment policy and over the past year, several local Medicare carriers, the Health Care Financing Administration (HCFA) and some private insurance companies have been evaluating their payment policies with regard to pallidotomy. The result has been a wide variety of payment policies for this procedure.
We have initiated a multi-pronged effort to address the problem, with the goal being to have Medicare and private payers adopt a national coverage policy. First, we have been in regular contact with HCFA officials. In February, for example, we met with HCFA officials to urge the agency to establish a national Medicare coverage policy in support of stereotactic pallidotomy, with and without microelectrode recording, as a treatment for Medicare patients with Parkinson’s Disease. As a result of this meeting, HCFA convened a subgroup of its Technical Advisory Committee to continue evaluating the advisability of developing such a policy.
Second, we are conducting a survey of neurosurgical departments at academic centers, state neurosurgical societies and others to determine whether or not local Medicare carriers are providing reimbursement for pallidotomy (CPT code 61720). We plan to use the data gathered in furtherance of a national reimbursement policy from Medicare
Art Day, MD, and Kim Burchiel, MD, recently represented organized neurosurgery at the National Blue Cross/Blue Shield Technical Advisory Committee meeting. They report it is likely that pallidotomy will be reimbursed, but the local Blues will continue to determine to what extent.
Another controversial issue that we are tracking involves the use of stent devices in the carotid artery. The Society of Cardiovascular and Interventional Radiology has approached organized neurosurgery about issuing a joint statement regarding stents that takes the position that this is a promising application of the device but research is needed to validate the procedure.
Currently, the stent’s use in the carotid is not approved and no controlled setting is in place to provide the needed outcomes information. L.N. Hopkins, MD, is in the forefront of an effort aimed at getting the Food & Drug Administration (FDA) to grant an Investigational Device Exemption (IDE) to do research on the stent. We are also trying to get HCFA to pay patient expenses associated with carotid stents in any approved research project.
Dr. Day and Marc Mayberg, MD, are organizing a response on this issue. This will include preparing a position paper on stents in the carotid, presenting that stance to the FDA and HCFA, trying to get access to training for neurosurgery residents, and developing a CME course for practicing neurosurgeons.
AANS Liaison with the RRC for Neurosurgery
I traveled to Jackson Hole, Wyoming, on June 29th to attend the policy and business sessions of the Residency Review Committee (RRC) for Neurosurgery, acting as an advocate for the issues of concern to our AANS constituency. In that meeting, we were able to address some of the concerns of our Pain Task Force, specifically, the inclusion of pain management under Neurosurgery Program Requirements as they will be enumerated in the next edition of the Graduate Medical Education Directory.
AMA President’s Forum
From July 25-26 in Washington, DC, I had the privilege of representing neurosurgery at the American Medical Association’s (AMA) President’s Forum. This annual event brings together the leaders of various medical associations for briefings on current trends impacting medical practice. I was joined by our new Executive Director, Robert E. Draba, PhD, CNS President Stephen Haines, MD, and CNS President-Elect Marc Mayberg, MD.
There were a number of excellent presentations and I will highlight a few of those here.
Stuart M. Butler, Vice President and Director of Domestic and Economic Policy Studies for the Heritage Foundation, spoke to us about his belief that a basic conundrum was at the heart of today’s health care delivery system. He pointed out that in every other service system, the users of that service control the dollars spent, but not with health care. He gave the analogy of a dog that is taken to a veterinarian, but which has no say in negotiating the cost of its treatment. We need a system that is more sensitive to payers, he said. Obviously, Mr. Butler is enthusiastic about Medical Savings Accounts.
Lawrence Atkins, Senior Vice President of Jefferson Government Relations, was a bit more persuasive. He concurred with Butler’s analogy but also advanced the notion that there’s a knowledge disparity between the dog and the vet. Butler’s recommendations, he felt, would result in the public handing over their collective credit cards to the vet and letting the vet and the dog decide what was equitable.
For the foreseeable future, he said, there will be pressure to define and make accountable the concept of disease management. Eighty percent of payers’ costs are for chronic diseases, which are hard to isolate into a simple diagnosis and curative treatment method, thereby holding the physician “accountable” for outcome in the usual straightforward or formalistic sense. Mr. Atkins also sees a growing dominance of purchasing coalitions as employers grow uneasy about managing health plans. They don’t see themselves as regulators, just purchasers.
Willis Gradison, President, Health Insurance Association of America, told us he sees health insurance going in the direction of defined contribution plans, that is, employers providing a certain amount of dollars to their employees and saying, “You decide how you want to spend it.”
Keynoter Gail R. Wilensky, PhD, spoke about “Current Trends in Health Care.” She hammered away at one message: decisions are being deferred that will become more onerous every year that they are postponed. The critical mass of baby boomers will reach age 65 and become eligible for Medicare in the year 2010, she pointed out.
Ms. Wilensky estimates that there is no better than a 50/50 chance that, after the election this November, Congress and whomever is President will summon up the courage to do anything about entitlements — 1997 offers no forcing event. According to her, if we wait until the year 2001 the abrupt changes that will be necessary in payments to providers, hospital support, and education funding will hurt all of us far more drastically than the patients. Just because it is patently obvious to everyone that gradual changes beginning now are imperative, there is no reason to believe that they will occur.
We also heard from Clifton R. Gaus, MHA, ScD, Administrator, Agency for Health Care Policy and Research (AHCPR), who talked about “Assessing and Improving the Quality of Practicing Physicians — Organized Medicine’s Role.” He gave three examples of what he termed “quality imperatives” with known defects: anticoagulation gives stroke protection but only 25% of those with atrial fibrillation are so treated; 25% of mammograms are allegedly misread; and recent studies show a 14% rate of medication errors with inpatients.
He discussed quality improvement mechanisms, quality outcome and guideline developments — and there is no shortage of each. The AHCPR now has a Guidelines Clearing House service where they will provide information about the source of a particular guideline and a quality evaluation.
According to Mr. Gaus, the sheer magnitude of the problem and limited resources have dictated a trend away from formal guidelines – at least from the standpoint of AHCPR. In response to a question about degrees of illness being factored into outcomes evaluations, he replied, “If outcomes research doesn’t have the science to measure that then they aren’t measuring quality.”
He concluded with the statement, “Non-MDs can change care, but only those who provide care can improve care.”
Leadership Meetings
The weekend of August 3rd was a busy one indeed, filled with meetings of the AANS Executive Committee, the AANS/CNS Joint Officers, and the Officers of the various Joint Sections. The discussions were much too numerous to report in any detail here, however, I will provide some highlights.
Our attorney, Russell Pelton, Esq., gave a detailed report on the status of the pedicle screw litigation in which both AANS and CNS are defendants. He provided an excellent overview of the legal issues surrounding the alleged promotional center activity claimed by plaintiffs in this case.
The question he addressed was a practical one: What constitutes prudent organizational and educational behavior in this litigious environment? This is a particularly sensitive situation as it applies to those asked to conduct hands-on, surgical educational courses. That has traditionally been an accepted part of both our Professional Development Program (PDP) courses and our Annual Meeting Special Courses.
As Mr. Pelton explained, workshop materials can only be used to demonstrate Food and Drug Administration (FDA)-cleared uses of products, and are not to be used to demonstrate off-label uses. The current FDA interpretation is that providing devices in workshops alone constitutes “support,” and, if off-label use is demonstrated in any workshop, the FDA views such “support” of that course by companies as “promotion of products for an off-label use,” and therefore, “not permissible.”
Although, Mr. Pelton emphasized, the FDA statement is directed to companies, the basis for the lawsuit in which we find ourselves a defendant is that we should be following the intent of those instructions as directed. He and the CNS counsel will cooperate in assembling and making available to our educators some guidelines to follow.
In other matters related to pedicle screw, you may have seen an editorial (“A Screwy Way to Treat Companies”) in the July 16, 1996, edition of the Wall Street Journal regarding the pending litigation. Although the writer focused on the ramifications impacting Sofamor Danek, it did present a good overview of the various issues involved. The article, however, did not adequately describe the effect of this litigation on patient care, the future of scientific research, nor the growing reluctance of medical societies like our own to provide educational forums about pedicle screw for their members for fear of being sued.
Consequently, Dr. Haines and myself, working in cooperation with the AANS Communications Department, developed a letter to the editor of the Wall Street Journal describing the concerns of organized neurosurgery. Although the letter was not published, we will continue to speak out whenever the opportunity presents itself. For your information, the text of that letter has been printed elsewhere in this issue of the Bulletin.
It was announced that this coming November our Long Range Planning Committee will present to the Board of Directors a Financial Strategic Plan for the AANS. We will have to agree on some limited fundamental priorities, correlate them with where we focus our expenditures and then stick by our priorities.
We have to maintain a sound financial foundation and providently conserve our resources. It may well be that we will have to focus on a half dozen important endeavors and let some other traditionally supported activities look elsewhere for support.
The Future Sites Committee reported it had reevaluated its previous recommendations for Annual Meeting locations and it appears that Toronto is our best bet for 2001 and Chicago is their recommendation for 2002.
As previously noted, I have only been at this for three months. However, a lot has happened and I am confident that we are on course. I hope that if you have questions about the activities of your leadership you will be in touch with me. In the meantime, I will continue to keep you informed about our progress.