1. CANS to employ lobbyist

2. Annual Meeting Topics Pertinent

3. AMA Guide for Work Comp disability now the law

1. CANS Board votes to employ lobbyist
Departing from its long held opinion that California Neurosurgery will be adequately served by feeding our input to the CMA and/or other specialty groups, the Board voted to engage a lobbyist to represent our interests in Sacramento and with various state agencies. This issue came to the fore when the state orthopedists and anesthesiologists, both of whom employ lobbyists, informed CANS that a coalition representing specialty interests in the current Division of Workers’ Compensation (DWC) plan to restructure the Official Medical Fee Schedule (OMFS) no longer adequately served their interests and that they were going to work directly on the DWC via their lobbyists.

This information left CANS with the CMA as our only strong input in this debate. Noting that the CMA has a long history of well representing California physician’s interests but because of its broad physician member base, which is predominately non-surgeons, it may not pursue the interests of Neurosurgery with the vigor or focus we may desire, the Board decided it was time for us to be more aggressive.

The tariff for a good lobbyist is about 50K a year, a figure that well exceeds CANS’ reserves and that equals our annual income from dues. Considering that our annual meeting, with its anemic attendance, generally just breaks even, the Board felt the only way to pay for this more pro-active approach was to raise dues to the $500 level for actively practicing CANS members (Senior and other membership categories dues remain unchanged).

As of press time, the lobbyist has yet to be engaged pending receipt of dues payments at the new level.

“It is time for California neurosurgeons to get very serious about pursuing and protecting their interests,” said Michael Edwards, CANS President. “If the DWC adopts an OMFS based upon some pejorative form of RBRVS, we will lose immensely more than $500/year per neurosurgeon,” he added.

This is an area where a CANS lobbyist would be very useful.

2. Annual Meeting highlights

The annual meeting on 1/22-23/05 in San Jose was very informative.
a) CANS has about 230 active members which I would estimate is about one-half of the actively practicing neurosurgeons in California.

b) New Board Directors are Pat Johnson (LA metro), Kimberly Page (Redding) and Eldan Eichbaum (Santa Rosa). They replace Mike Robbins, Edie Zusman and Jose Rodriquez who were thanked for their three years of service. Mike Edwards (Stanford) is President for this year, Jack Bonner (Fresno) is our new President-Elect and Mike Robbins (Sacramento) is our new Treasurer.

Michael S. B. Edwards, M.D., President

c) We collect about 50K in dues, spend about that much running the organization and have about 35K in reserve. The annual meeting tends to break even.

d) The meeting session on Workers’ Compensation was enlightening. The issue of Medical Provider Networks and “Silent PPOs” was discussed in detail and was the subject of a “CANS Alert” E-mailed or faxed on 1/27/05 to all active members. The imposition of the AMA Guidelines to determine impairment was discussed (see 3. below). Of note was that the Primary Treating Physician is no longer presumed to be correct and treatment must for now follow the American College of Occupational and Environmental Medicine (ACOEM—pronounced “A-com” by those in the know) Guidelines. I bought those rather expensive guidelines and they were written to manage treatment of injuries in the first 90 days following injury. Since neurosurgeons usually won’t be considering operative intervention during the first 90 days, the question then becomes how does one justify a proposed operation to adjusters and their utilization review corps, since all treatment outside the ACOEM guidelines is supposed to be based upon “evidence based, peer reviewed” information?

I don’t know about you, but I do not walk around with a compendium of articles in my head that support the performance of a discectomy on an injured worker with a clear HNP on MRI and a clinical radiculopathy unresponsive to 6 months of conservative care. I was told at the meeting that if you quote specialty society guidelines for surgery, that should suffice. And where do you find those? Well, some guidelines are available on the American Association/Academy of Orthopaedic Surgeons (AAOS) web site (–site map—Research and Scientific Affairs—Guidelines—LBP guideline phase II). Both the AANS and CNS web sites do not contain useful spine surgical guideline information and an urgent request to the AANS from CANS about such guidelines did not produce useful information about surgical guidelines for us to use.

The Administrative Director (AD) of the Department of Industrial Relations (DIR) is supposed to adopt additional or other guidelines for care than those of the ACOEM and the CMA has lobbied her to reject corporate guidelines (McKessen, Milliman & Roberts, etc.) and adopt those of all national specialty groups recognized by the ABMS or the Medical Board of California. It is unclear what Neurosurgery can contribute considering the previous paragraph. This is an area where a CANS lobbyist would be useful.

This year’s attack by the plaintiff bar is expected to focus on raising the $250K limit on pain and suffering using a child’s case of purported medmal injury wherein the child is featured showing much chronic disability and painful suffering. The thesis will be that $250K is particularly not enough for this unfortunate person and generally should be raised for everyone to reflect something like inflation. Had an inflation rider been part of the MICRA pain and suffering limit all along, the limit today would be $900K. Those who should know feel we cannot be sure that Governor Schwarzenegger would veto such a change so the battle will be joined at the legislative level by the CMA. This is an area where a CANS lobbyist would be useful.

It was also pointed out that the federal bill addressing tort reform in medical malpractice cases touted by President Bush suffers from the inclusion of hospitals, HMOs and drug and device manufacturers in what it covers which increases the number and vigor of opponents of the measure beyond that which would occur if it only addressed physician medmal limits.

f) Expert Testimony in medmal cases
The California Attorney General has apparently ruled that you cannot be sued for providing testimony in a medmal case. He did not define that testimony as constituting the practice of medicine but did opine that such testimony, when egregious, may be a cause for a report to the Medical Board of California (MBC) for unprofessional conduct.

g) Neuro-Trauma coverage
This session, designed to highlight the miseries of the LA metropolitan area neuro-trauma coverage, brought out some interesting numbers. Apparently about 500 million dollars were spent in 2004 by hospitals in California to pay for specialist ED coverage. (I remember that figure was about zero in 1986 when CANS first proposed that we get paid for such coverage at trauma centers.) These days, compensation levels for neurosurgeons to cover EDs vary from $100/day to $2000/day with a few noteworthy outliers ($2500/night in Sacramento; $3600/24 hours in Bakersfield—with the latter unable to find any takers). Seventy EDs have closed up shop over the past 10 years. There appears to be no concerted effort by any legislative group or hospital system to make ED coverage a condition of licensure or staff membership but such maneuvers are being considered by some. This is an area where a CANS lobbyist would be useful.

3. AMA Guides now the law
For all work comp cases declared permanent and stationary after 1/1/05, the patient’s impairment will have to be addressed using the AMA Guides to the Evaluation of Permanent Impairment, 5th edition. I don’t know about you, but I have avoided proficiency in applying those guides for the past 25 years since learning the California disability rules which applied to 99% of patients I rated over that time frame. Since we shouldn’t ever be too old to learn, I ordered the Guides plus supporting books (Master the AMA Guides, The Guides Casebook and The Practical Guide to Range of Motion Assessment) from the AMA bookstore. All arrived and it looks like a lot of reading. Anyone needing to learn and use the Guides with any degree of speed might consider taking an instructional course. I have signed up for one being given on 3/12/05 at the John Wayne Orange County Airport Hilton by a Chicago outfit who detected a need for California physicians to learn how to use the guides. This full day course costs $395 and apparently the 8 CME hours are CA QME/CME approved (800-234-3490). The CMA has indicated it will provide training programs later this spring which strikes me as being a day late and a dollar short.

The AMA guides are for determining impairment and Comp raters will have to turn that into disability (impairment translated into workplace issues) and money which fortunately will not be our job.

Randy Smith, M.D.

Correction: In the CANS Alert #1, I implied the State Compensation Insurance Fund (SCIF) was choosing docs in the Blue Cross Prudent Buyer network to be their MPN. It turns out they have their own MPN and are only using Blue Cross for facility choices, at least in San Diego. Interestingly, in the San Diego metro area, the SCIF MPN is populated with numerous orthopaedic spine surgeons and one neurosurgeon.

The above comments are my own and generated from what I think I heard during the CANS Board meeting on 1/21/05 and general meeting on 1/22/05 in San Jose.