AANS Neurosurgeon Spotlight: March 2017 – Concurrent Surgery

AANS-Magazine-Feb-2017-concurrent-surgery-ET2AANS Neurosurgeon is the official socioeconomic publication of the American Association of Neurological Surgeons (AANS) and features information and analysis for contemporary neurosurgical practice. It focuses on topics related to legislation, workforce issues and practice management as they affect the specialty of neurosurgery. The March 2017 edition of AANS Neurosurgeon explores the theme, “Concurrent Surgery,” discussing the impact this type of practice within the field has on neurosurgeons, neurosurgical training and patients.

Is the practice of concurrent surgery ethical? How does this impact the education process for neurosurgeons-in-training? What impact does concurrent surgery have on patients, and how is the “critical portion” of the surgery defined? Without concurrent surgery practices, will future neurosurgeons be inadequately trained? These questions, along with many others, are answered throughout a number of articles in this publication.
Some highlights of the issue:

Elsewhere in the issue, readers can check out additional theme-related articles, as well as book reviews and updates from the Washington, D.C., office via its “Washington Watch” column.

In addition to its regularly updated Twitter page, AANS Neurosurgeon also boasts Facebook page. Follow both social media accounts to read articles and stay current on the latest neurosurgical news.

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Medicare Expenditures Variation after Implementation of the Affordable Care Act

kimonKimon Bekelis, MD
Department of Neurosurgery, Thomas Jefferson University
Instructor, the Dartmouth Institute for Health Policy and Clinical Practice

A major goal of the Affordable Care Act (ACA) was to curb the rising cost of health care and rationalize Medicare spending across different areas of the US.1 For this to be achieved, the law integrated provisions aiming to improve access to care and reform the health care delivery system. This issue has been passionately debated and survived multiple legal battles.

Critics of the law point out that:

  • Health care premiums have increased for most beneficiaries; and
  • Some beneficiaries have been forced to change plans and providers.

Proponents of the ACA counter that:

  • Insurance coverage has expanded to more Americans; and
  • Medicare spending growth rate has stabilized over the past several years.
Figure 1. Rates of per-beneficiary Medicare spending nationally and among nine big states between 2009 and 2014.

Figure 1. Rates of per-beneficiary Medicare spending nationally and among nine big states between 2009 and 2014.

Although prominent health economists have recognized the mainly flat growth rate in health care spending in the years after the implementation of the ACA, they are not necessarily attributing this trend to a causal relationship with the enactment of the law.2 Figure 1 demonstrates flat rates of per-beneficiary Medicare spending nationally and among nine big states between 2009 and 2014.

Figure 2. Hospital Referral Region based map of the US showcasing the total Medicare spending per enrollee in 2010.

Figure 2. Hospital Referral Region based map of the US showcasing the total Medicare spending per enrollee in 2010.

The marked regional variation in the patterns of health care spending has attracted the interest of health economists over the years and was one of the seeds of the ACA. These disparities gave birth to The Dartmouth Atlas,3 a comprehensive analysis quantifying the differences in regional spending. For this project, the U.S. was divided into Hospital Referral Regions (HRR), based on referral patterns.

Medicare spending, adjusted for price and patient characteristics, demonstrated striking variation across the U.S. before the implementation of the ACA in 2010 (Figure 2). Medicare spending per beneficiary ranged from $6,911 to $13,824. These disparities have been attributed to inefficiencies in health care delivery, and differences in local marketplaces.4

Figure 3. Hospital Referral Region based map of the US showcasing the total Medicare spending.

Figure 3. Hospital Referral Region based map of the US showcasing the total Medicare spending.

Looking at the same parameters in 2014, several years after the implementation of the ACA, we observed similar regional variability in Medicare spending (Figure 3). Medicare spending per beneficiary ranged from $6,632 to $16,125. On its surface, this is surprising given the premise of the ACA to correct inefficiencies in health care delivery. However, the persistence of these disparities likely reflects the performance of established delivery systems, which would be resistant to national policy change. Alternatively, it could also reflect the impact of variable sociodemographic factors and differential burden of disease on Medicare spending, which was not affected by changes in legislation.

In conclusion, although the ACA included a number of provisions designed to encourage greater efficiency in Medicare, profound differences in Medicare per beneficiary spending in different parts of the country remain.

Editor’s Note: We encourage everyone to join the conversation online by using the hashtag #HealthReform.


  1. Fisher ES, McClellan MB, Safran DG. Building the path to accountable care. N Engl J Med. 2011;365(26):2445-2447.
  2. Skinner J, Chandra A. The Past and Future of the Affordable Care Act. JAMA. 2016;316(5):497-499.
  3. Practice TDIfHPaC. The Dartmouth Atlas of Healthcare. http://www.dartmouthatlas.org. Accessed February 11, 2017.
  4. Bekelis K, Roberts DW, Zhou W, Skinner JS. Fragmentation of care and the use of head computed tomography in patients with ischemic stroke. Circ Cardiovasc Qual Outcomes. 2014;7(3):430-436.
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Open Payments: What Neurosurgeons Need to Know and How Accurate is the Data?

cathyannAnn M. Parr, MD, PhD, FAANS, FRCSC (left)
Assistant Professor, Neurosurgery, and Director, Spinal Neurosurgery
University of Minnesota
Minneapolis, MN

Catherine Miller (right)
Neurosurgical Resident, University of Minnesota
Minneapolis, MN

doctorsThe Open Payments system also known as the Sunshine Act, is a federal program required by the Affordable Care Act (ACA) that collects information about the payments drug and device companies make to physicians and teaching hospitals. The data it collects is provided to the public each year. The purpose of this system was to increase transparency around financial relationships between physicians, hospitals, and drug and device companies. While the landscape of health care is ever-changing, it is important to keep informed on laws, which directly affect the neurosurgery field. Below are some quick facts about the Sunshine Act that every neurosurgeon should know.

What is reported?

  • Direct or indirect payments or other transfers of value made to covered recipients (physicians and teaching hospitals), and physician owners or investors; and
  • Certain ownership or investment interests held by physician owners or investors, or their immediate family members.

Who is reported on?

  • Covered recipient physicians — MD, DO, dentists, podiatrists, optometrist and chiropractors (resident-in-training and non-physician personnel are excluded);
  • Covered recipient teaching hospitals — those that receive payments under Medicare direct graduate medical education; and
  • Physician owners or investors.

Who is responsible for reporting?

  • Manufacturers which engage in the production, preparation, propagation, compounding, or conversion of a covered drug, device, biological or medical supply; and
  • Group purchasing organizations (GPOs) which purchase, arrange for or negotiate the purchase of a covered drug, device, biological, or medical supply.

What is the process?

  1. Data Collection: Manufacturers/GPOs collected data regarding payments made to physicians, hospitals or physician owners/investors;
  2. Submit Payment Data: Manufacturers/GPOs submit data to CMS Open Payments system;
  3. Review & Dispute Data: Physician and teaching hospitals can review all records submitted about them by reporting entities and dispute any incorrect data;
  4. Review & Correct Data: Manufacturers/GPOs can review disputes and correct any data; and
  5. Data Displayed: The CMS public website displays all data.

How can I view my data?

To review and dispute any data reported in the Open Payments system before its publication, users must follow the two-step registration process to register for the Open Payments system.

  1. Register self in Enterprise Identity Management (EIDM) via CMS Enterprise Portal; and
  2. Register teaching hospital and self in the Open Payments system.

Physicians are vetted using information supplied during Open Payments system registration, including name, NPI and state license.

When can review and disputes take place?

The review, dispute and correction period consists of:

  • 45 days for data review and dispute by physicians and teaching hospitals; corrections can also be made by reporting entities;
  • 15 days immediately following the 45-day period for reporting entities to continue to make corrections; and
  • Records with a new dispute initiated after the 45-day review and dispute period will be published as original attested-to data in the initial data publication.

What resources are available for physicians?

There are many resources on the CMS Open Payments website page, including:

  • Open Payments User Guide
  • Open Payments Review and Dispute Overview for Physicians and Teaching Hospitals
  • Register for the CMS listserv, via the Open Payments website, to receive e-mail updates about Open Payments
  • Contact the Open Payments Help Desk

What is the most recent data?

In June 2016, the CMS released their data for the 2015 year.

  • 9 million total records, 0.13% of which were disputed
  • $7.52 billion in payments to physicians and teaching hospitals
    • $2.60 billion: general (non-research related) payments
    • $3.89 billion: research payments
    • $1.03 billion: ownership or investment interests
    • As innovators in a highly technology-dependent field, it is no surprise that neurosurgery ranked second among the physician specialties regarding payments received (average total payment per physician = $26,080)

When is the next reporting period?

The 2016 Open Payments review and dispute period begins on April 1, 2017. CMS will publish the 2016 data and updates to 2013, 2014 and 2015 program years on June 30, 2017.

The review and dispute period will remain open until May 15, 2017. Physicians and teaching hospitals must initiate their disputes during this 45-day review period for any disputes to be addressed before the June 30th publication.

Is the data accurate?

There has been ongoing concern regarding the accuracy of this system and in what ways the public may interpret the data. To this end, a study was performed investigating the accuracy of the Open Payments System in regards to neurosurgeons and found several inaccuracies. It searched over 15 million records from 2013-2014 and found that only 62-68 percent of neurosurgeons in the database were correctly identified. Forty-one residents were classified as neurosurgeons, despite the fact that residents are not to be included in the database according to regulatory stipulations. There were also some physicians who were classified as neurosurgeons but were actually from different specialties.

It is without question that collaborations between physicians and biopharmaceutical and medical technology organizations improve patient care and contribute significantly to scientific innovation. However, given the inaccuracies with Open Payments system, it’s also important for all to consider all the implications of disclosure, transparency, and context as more information is publicly released by the administration, and more news outlets delve into the numbers.

Editor’s Note: We encourage everyone to join the conversation online by using the hashtag #HealthReform.

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