Minnesota Neurosurgical Society

Presidential Address
Minnesota Neurosurgical Society 2010

Members and guests of the Minnesota Neurosurgical Society, fellow learners, thank you for this opportunity to address you today. I am pleased to report that the health of our organization continues to improve. Over the last three years, we have written bylaws, incorporated the society and hosted successful CME conferences. The AANS is our joint sponsor for this year’s meeting and in 2010 we received more that $10,000 in unrestricted educational grants. Our financial assets are twice what they were in 2007. This spring, Dr. Lanzino was elected Secretary/Treasurer and is now our President-elect. Although I am quite proud of all that our organization has been able to accomplish, I am humbled by what remains incomplete or undone.

As our Society strengthens, the world around us is rapidly changing. We believe that healthcare in the United States needs to be improved, but we are concerned that the current reforms will not accomplish this. Perhaps we feel overwhelmed by the scope and complexity of these looming changes. We are disillusioned by the politics of reform and frustrated by a process which has not welcomed our advice about what we believe would be in the best interests of our patients.

As neurosurgeons, we face overwhelming and difficult problems every day at the bedside. We give clarity and often hope to our patients when others can only see uncertainty and despair. We empower our patients one step at a time and, when possible, finesse them back to health.

The debate over healthcare reform is beginning, not ending. The tasks before us are enormous and there will be much for us to do just within our state. We can use these same strengths and skills to bring clarity and hope to healthcare reform. We can empower our profession one issue at a time and, when possible, finesse reform toward sensible improvements.

To do this, we must learn to work together finding a voice through our professional societies. The day we collectively become silent about things that matter most-service to patients, scholarship and education- is the day that our profession fails.

The way we must service our state societies is very different today than in the past. The Pennsylvania Neurosurgical Society traces its roots back to 1884, but first met as an independent group in 1959. William Whiteley’s tape recording of this meeting is still available. Several patients were presented and openly discussed. The first patient had post-herpetic neuralgia and was treated with pre-frontal lobotomy; a second patient had frostbitten hands and was treated with sympathectomy and; a third patient had painful carpal tunnel syndrome. Considerable discussion focused on the carpal tunnel patient as most audience members expressed doubt that such a syndrome actually existed. The final presentation was made by Henry Shoemaker who described a method of selective intrathecal injection of boiling water for the control of metastatic pain.

For neurosurgeons of that era, socioeconomic affairs were private matters between neurosurgeons and their patients and not a discussion topic at meetings. But in the 1960’s, the world changed. The formation of Medicare transformed medicine from a private, benevolent service into the public, complex and expensive healthcare industry we know today. Socioeconomic issues began to impinge upon the practice of neurosurgery and in 1963, the Congress of Neurological Surgeons established the Socio-Economic Committee.

Nine years later, Congress passed legislation requiring each state to set up review organizations to monitor medical care.  Recognizing the importance of high quality neurosurgical care, the AANS and the CNS initiated a program to actively form state neurosurgical societies to interact with these review organizations. Today there are 38 state neurosurgical societies. Eight additional states are represented by regional societies which provide leadership in a broad sense, but do not consider issues unique to individual states. Alaska, Nevada, North Dakota and Wyoming have no formal mechanism for state neurosurgical representation.

Our world today is very different from the one William Whiteley recorded in1959. As a profession, we worry that we will not be able to give our patients the care they need because of financial and other socioeconomic problems. Through all this, our relationship with our patients has become more complex. The illusion generated by the irresponsible rhetoric of our public leaders leads our patients to believe that our motives are suspect and that we care more about financial return than our patients. Our President says that surgeons prefer to amputate feet for fifty thousand dollars, rather that treat diabetes, and that otolaryngologists prefer to do tonsillectomies needlessly because it pays more than just prescribing antibiotics. Senator Schumer from New York says we bill patients four thousand dollars for waving to them while they lie on a gurney in the hallway. Their innuendos about our motives are just wrong. As the healthcare reform debate churns onward, our profession will be drawn more deeply into matters of finance, resource rationing and medical malpractice rather than the practice of medicine. It will be our responsibility at every step of this process to be genuinely mindful of and serve the best interests of our patients. If we are not our patients’ advocates, ultimately we will have no value to those we serve.

As we continue to struggle to understand what healthcare reform will actually mean, I am struck by one important fact: Passage of the Patient Protection and Affordable Care Act is not the end, but is an important way just the beginning of the discussion and implementation of healthcare reform. When I first heard Nancy Pelosi say “but we have to pass the bill so that you can find out what is in it” I thought that she was being facetious, but, in the final analysis, she was correct. It will take years to set up the structures that it mandates. Federal agencies will need time to interpret the bill, for the administration to appoint and staff the various commissions and agencies created by the bill, and for the Congress to pass the various subsidiary pieces of enabling legislation. As reform moves forward, the Patient Protection and Affordable Care Act gives the Secretary of Health and Human Services broad powers to dictate the direction of reform. Every piece of this bill’s implementation will be grounds for massive inside-the-Beltway turf battles and debates. Regardless of the outcome of the twenty constitutional challenges to this legislation brought by states, a significant portion of how we deliver healthcare will be determined within each state. State neurosurgical societies may be more important now than at any time in the past.

Through our societies, we must seek out partners and allies at the state and national level, whether they are other professional societies, business coalitions or community organizations. Although the recent action of the AMA has left us disenchanted, Peter Carmel is now the President-elect of the AMA. Having a neurosurgeon in this position provides an opportunity for us to effectively partner with the AMA once again. Within Minnesota, neurosurgeons have an untested opportunity to collaborate with the Minnesota Medical Association and there is much more that we could do with other state neurosurgical societies through the Council of State Neurosurgical Societies.

We should also collaborate with other surgical specialties through the American College of Surgeons. The College supports federally controlled regionalization of emergency care and redistribution of residency training positions based on state population. It will fall upon us to educate other surgeons how regionalization of emergency care could affect neurosurgery patients in Duluth, Saint Cloud or Mankato or how Minnesota’s two neurosurgery training programs, both of which draw patients from well beyond our state borders, will change if resident training positions are redistributed by state population.

At the national level, neurosurgery is fortunate to have skillful and experienced individuals such as Katie Orrico to advocate on our behalf. Within each state, however, we are fully dependant on the energy and ingenuity of volunteer neurosurgeons.

Healthcare reform changes how we are compensated. Beginning in 2012, healthcare providers may organize into local Accountable Care Organizations that will be eligible to share in Medicare savings rebates. By 2013, these organizations will accept bundled and capitated payments. By 2014, each state must establish a Health Benefits Exchange offering certain benefits and meeting certain cost-sharing requirements. In Minnesota, we are likely to see continued evolution of General Assistance Medical Care, MinnesotaCare, the Health Care Access Fund and the provider tax. These changes will profoundly affect the dynamics of healthcare within Minnesota and how resources are apportioned favoring those in our profession who figure out how to collaborate and organize with other professionals.

Just as we want to know if we are sending our children to a good school or buying a reliable car, we should know if our surgeons are competent. Public disclosure of physician performance is now required by law. Initially passed by the Minnesota State Legislature in 2008, passage of the Patient Protection and Affordable Care Act now makes this a federal requirement. It is likely that third party payers and local and regional groups will also publish physician rankings. The federal government plans to use administrative data to rank physicians according to their cost of care. Clinical outcome, patient satisfaction and overall value of care will not factor into this ranking. Under this scheme, doctors who care for the sickest, most complicated patients will be penalized because of their high costs rather than recognized for the value they bring to their patients and communities. Numerous studies have concluded that cost rating of individual physicians is inaccurate, misclassifying as many as 2/3 of physicians in certain specialties. Currently 46 state, regional and national medical societies have partnered with the AMA to challenge this approach by the Center for Medicare and Medicaid Services.

The failure of the Patient Protection and Affordable Care Act to address tort reform in a conclusive way is a disappointment. Howard Dean, who was Chairman of Democratic National Committee and a physician, when asked about this omission, said we simply did not want to take on the trial lawyers. Neurosurgery, perhaps more so than any other specialty, has been adversely affected by unfair medical malpractice claims. Starting in 2011, the Patient Protection and Affordable Care Act, awards demonstration grants to states to develop, implement and evaluate alternatives to litigation for resolving malpractice disputes. In neurosurgery, we already know that alternative approaches can be effective. By holding members strictly accountable for the content of their expert testimony, our national societies have reduced the impact of frivolous claims.

Regardless of where healthcare reform starts, all progress will be contingent and the solution of one problem will bring us face to face with another. State neurosurgical societies can have a significant impact.  Remember that it was the California Association of Neurological Surgeons that first identified that neurosurgeons were increasingly becoming the target of frivolous malpractice suites. Their advocacy led our national organizations to actively enforce professional standards of expert testimony.

It was the California Association of Neurological Surgeons that began surveying hospital stipends for neurosurgical emergency room coverage in 2003, identifying inequities and inconsistencies in hospital reimbursement behavior. The Association now shares ongoing survey results with California neurosurgeons and hospital administrators who are actively negotiating neurosurgical coverage contracts.

What can we in Minnesota do for our profession? The Minnesota Neurosurgical Society needs just one volunteer member to produce a regular newsletter keeping us informed as events unfold in Minnesota and elsewhere. At this critical time, nothing is more dangerous than sincere ignorance. We need one more volunteer member to serve as a delegate to the Minnesota Medical Association and another to serve as our delegate to the Council of State Neurosurgical Societies. Finally, we need a few volunteer neurosurgeons to serve on the Executive Committee as it is the executive committee that prioritizes our goals and leads this organization.

Even though we are a small society, we can and should make a difference. None of us in Minnesota need to be reminded how a single, small mosquito can change the tone within a room. By bringing clarity, hope, wisdom and finesse to this debate, we can empower reform and improve healthcare. The ultimate measure of our profession is not where we stand in moments of comfort and convenience but where we stand at times of challenge and controversy.