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2020 — A Year in Review

By Advocacy Agenda, Congress, Health Reform, Medical Innovation, Medical Liability, Prior AuthorizationNo Comments

While 2020 is a year that most people want to forget, the American Association of Neurological Surgeons (AANS) and the Congress of Neurological Surgeons (CNS) made significant strides in accomplishing its legislative and regulatory agenda, thus ensuring that neurosurgical patients continue to have timely access to quality care. Following are some highlights of these advocacy efforts.

Congress Prevents Steep Medicare Cuts

On Jan. 1, the Centers for Medicare & Medicaid (CMS) implemented the new CPT guidelines to report office and outpatient visits based on either medical decision making or physician time. These evaluation and management (E/M) services are valued in line with the AMA/Specialty Society RVS Update Committee (RUC) recommendations. Unfortunately, to comply with Medicare’s budget neutrality requirement, any increases must be offset by corresponding decreases, and CMS estimated that the 2021 policies would increase Medicare spending by approximately $10.6 billion. This necessitated significant cuts for many specialties, including an overall 6-7% payment cut for neurosurgery.

Faced with these steep Medicare payment cuts (and potential future cuts to the 10- and 90-day global surgical codes), in June 2020, the AANS and the CNS — with significant funding support from the Council of State Neurosurgical Societies and the Section on Disorders of the Spine and Peripheral Nerves — along with 10 other national surgical associations, founded the Surgical Care Coalition (SCC). The SCC launched a targeted, multi-faceted advocacy and public relations campaign to prevent these cuts. Specifically, the SCC advocated that Congress adopt legislation that would:

  • Increase the global surgery code values;
  • Halt implementation of the G2211 add-on code for complex E/M visits; and
  • Prevent any additional cuts resulting from the new E/M payment policies.

Working with the SCC and other physician and allied health professional organizations, the AANS and the CNS successfully advocated for legislation to prevent these cuts. On Dec. 27, 2020, President Donald J. Trump signed the Consolidated Appropriations Act, 2021 (H.R. 133) into law (P.L. 116-260) — a massive omnibus spending bill that includes nearly $900 billion for coronavirus relief and an additional $1.4 trillion spending package to fund the federal government through the end of the Fiscal Year 2021. Specifically, the legislation:

  • Prevents steep Medicare cuts by earmarking $3 billion to help offset the budget- neutrality adjustment and by delaying for three years the new G2211 add-on code for certain complex office visits;
  • Extends the moratorium on the 2% Medicare payment sequester for an additional three months through March 2021, allocating $3 billion for this purpose;
  • Increases payments for the work component of the MPFS in areas where labor cost is determined to be lower than the national average through Dec. 31, 2023; and
  • Temporarily freezes alternative payment model (APM) payment incentive thresholds for two years, allowing more physicians to qualify for the 5% APM bonus payments.

As a result of this combined relief, overall, neurosurgeons should not experience any Medicare payment cuts (although the specific impact will depend on the mix of services provided) in 2021.

However, our work is not complete. The surgical community will continue to advocate for CMS to adjust the 10- and 90-day global codes to reflect the increased values of the E/M portion of these codes. In that regard, on Dec. 1, Sen. Rand Paul, MD, (R-Ky.) introduced S. 4932, the “Medicare Reimbursement Equity Act.” If enacted, this legislation would require CMS to value the E/M portion of the global codes equal to the stand-alone E/M codes.

Progress Made in Reforming Prior Authorization

For the past two years, the AANS and the CNS have been tireless in their efforts to reform prior authorization in the Medicare Advantage (MA) program. Significant progress has been made, setting the stage for reforms in the coming year. Neurosurgery-backed legislation — the “Improving Seniors’ Timely Access to Care Act” (S. 5044 / H.R. 3107) — garnered overwhelming bipartisan support from nearly 300 members of Congress. If enacted, this bill would reform the use of prior authorization in Medicare Advantage (MA) through a streamlined and standardized process that focuses on increased transparency and accountability. The bill reflects a neurosurgery-supported consensus statement on prior authorization, developed by leading national organizations representing physicians, hospitals and health plans.

Specifically, the legislation directs the Secretary of the U.S. Department of Health and Human Services to:

  • Establish a real-time, electronic prior authorization process;
  • Minimize the use of prior authorization for routinely approved services;
  • Ensure prior authorization requests are reviewed by qualified medical personnel; and
  • Require MA plans to report on their use of prior authorization, including delay and denial rates.

This legislation will be reintroduced in the 117th Congress. More information is available from the Regulatory Relief Coalition, of which the AANS and the CNS are founding members.

Protecting Patients from Surprise Medical Bills

The AANS and the CNS have been advocating for federal legislation to protect patients from unanticipated medical bills (otherwise known as “surprise” medical bills) while at the same time providing for a fair process for resolving payment disputes. Organized neurosurgery adopted a set of principles for a balanced solution to the problem. After more than two years of sustained advocacy, Congress incorporated into the Consolidated Appropriations Act, 2021 (P.L. 116-260) the “No Surprises Act,” which applies to federally-regulated plans, including ERISA plans, and does not preempt state laws governing state-regulated health plans. The provisions of the new law, which will be implemented on Jan. 1, 2022, meet many of organized neurosurgery’s principles and include the following elements:

  • Patients are protected from surprise medical bills and only responsible for the in-network cost-sharing amount for out-of-network (OON) emergency services and other services provided in in-network facilities.
  • Insurers are required to make initial payments directly to OON providers for OON services within 30 days. The law does not define the payment rate.
  • If a provider objects to the payment, they may proceed to an independent dispute resolution (IDR) process.
  • The IDR process is baseball-style arbitration. There is no negotiation. Both parties submit a payment rate, and the arbiter selects one.
  • The arbiter may consider several factors, including median in-network rates and any other information the provider or health plan submits, other than billed charges, Medicare, Medicaid, CHIP and Tricare rates.

The AANS and the CNS will work with the incoming Biden Administration on the implementing regulations.

Supporting Quality Resident Training and Education

An appropriate supply of well-educated and trained physicians — both in specialty and primary care — is essential to ensure access to quality health care services for all Americans. Looming physician shortages — by 2033, the nation faces a physician shortfall of between 54,100 to 139,000 — threaten this access to care. To help ease this shortage and support quality resident training and education, the AANS and the CNS successfully advocated for legislation to increase the number of Medicare-sponsored residency training positions. The “Resident Physician Shortage Reduction Act” (S. 348 / H.R. 1763), with a total of 242 bipartisan cosponsors, would increase the number of available medical residency positions by 15,000 over five years.

While falling short of what is necessary to adequately address the looming physician workforce shortage, the Consolidated Appropriations Act, 2021 (P.L. 116-260) did provide funding for 1,000 additional Medicare-funded graduate medical education (GME) residency positions. The AANS and the CNS will build on this down payment by advocating for additional funding in the 117th Congress.

COVID-19 and the Global Pandemic

On March 13, 2020, President Trump issued an executive order declaring the COVID-19 pandemic a national emergency. Shortly after that, neurosurgical practices began temporarily suspending non-emergency neurosurgical cases and experiencing significant cash-flow challenges. Working with multiple coalitions of physician organizations in Washington, D.C., the AANS and the CNS stepped into high gear to advocate for financial and other relief for neurosurgeons.

Congress passed several COVID-19-related bills, which included vital assistance for physicians and hospitals. The Coronavirus Aid, Relief, and Economic Security (CARES) Act (H.R. 748) and the Paycheck Protection Program and Health Care Enhancement Act (H.R. 266) established and funded the Paycheck Protection Program (PPP), allowing neurosurgical practices to receive grants to help keep their employees paid and their practices afloat. The Consolidated Appropriations Act, 2021 (P.L. 116-260) expanded current PPP legislation, adding $284 billion in funding for the PPP and extending it through March 31, 2021. Legislation also allocated more than $175 billion to the Public Health and Social Services Emergency Fund, helping with bridge funding for neurosurgeons and the hospitals in which they practice.

The expansion of telemedicine, and increased payments for telemedicine services, helped neurosurgeons continue to take care of their patients remotely and will likely be an integral part of neurosurgical practices in the future. Finally, the AANS and the CNS led efforts to secure COVID-19-related medical liability protections. The CARES Act included liability protections for physicians rendering volunteer medical services during the COVID-19 public health emergency. In addition, Reps. Phil Roe, MD, (R-Tenn.) and Lou Correa (D-Calif.) introduced H.R. 7059, the Coronavirus Provider Protection Act, and Sens. John Cornyn (R-Texas) and Mitch McConnell (R-Ky.) introduced S. 4317, the “SAFE TO WORK Act.” Both bills would provide physicians protections from certain COVID-19-related lawsuits. The AANS and the CNS will continue to advocate for the adoption of COVID-19 related liability protections in the 117th Congress.

Turning the Corner to 2021

The inauguration of Joseph R. Biden, Jr. as the 46th president of the United States will bring with it a new administration, along with changes in the 117th Congress, mean new health care policy priorities will be front and center on the national legislative and regulatory agenda. While these changes present organized neurosurgery with new opportunities to continue advocating for sound health policy that improves patient care, 2020 will go down as a year in which the AANS and the CNS made significant positive strides for neurosurgeons and patients alike.

Katie O. Orrico, Esq.
AANS/CNS Washington Office
Washington, DC

Medicolegal Issues in Neurosurgery

By CSNS Spotlight, Guest Post, Medical LiabilityNo Comments

Virtually all neurosurgeons will have to deal with a medicolegal issue by the end of their career. Neurosurgeons have the highest annualized rate of lawsuits at >19%. Perhaps shockingly, even by age 45, approximately 88% of surgeons in high-risk subspecialties will have been involved in a lawsuit. This number elevates to >99% by age 65. The concern about professional liability lawsuits is, without a doubt, the highest profile medicolegal issue for neurosurgeons — even though many more issues other than litigation affect our daily medical practices. Medicolegal and socioeconomic topics such as neurosurgical workforce, contracting and employment, and payor/insurance issues such as coverage policies, reimbursement and prior authorization regularly impact each neurosurgeon’s practice in multiple ways — even if it is not immediately apparent.

We are all trained in both the science and art of medicine throughout those seven long years of residency. Yet, historically, very little attention is paid to educating neurosurgeons about myriad medicolegal and socioeconomic issues. There is a relative dearth of information on socioeconomic topics compared to matters concerning the science and practice of medicine in the literature. As such, during our residency and in our daily practice, we learn precious little about issues related to the social, political or economic aspects of neurosurgery. However, these issues consume so much of our time and significantly impact our practices.

To this end, the November issue of Neurosurgical Focus is dedicated to medicolegal issues that can be useful to neurosurgeons at all stages of practice. We hope that this issue will serve as a primer on the subject so that neurosurgeons can develop an appetite for regular reading about and involvement with these critical issues.

Articles in the Neurosurgical Focus’ November issue include:

Lastly, please note the hard work in this area that the Council of State Neurosurgical Societies (CSNS) has done for decades. The CSNS is the group in organized neurosurgery that addresses the confluence of medicolegal and socioeconomic issues and neurosurgical practice as neurosurgeons. It is jointly supported by the American Association of Neurological Surgeons and the Congress of Neurological Surgeons since its inception in 1972. It began as the Joint Socio-Economics Committee. It functions as a grassroots organization whose members are drawn from each state’s neurosurgical society. This structure allows it to be broadly representative of the whole of neurosurgery while at the same time being agile enough to deal with the rapidly changing landscape of these issues. In addition to delving into the November medicolegal issue of Neurosurgical Focus, neurosurgeons are encouraged to participate as active members in your state neurosurgical society to ensure that you remain an integral part of the CSNS.

Click here to read the press release and here for the complete issue of “Medicolegal Issues in Neurosurgery” in Neurosurgical Focus.

Editor’s note: We hope that you will share what you learn from our posts. We invite you to be part of the conversation on Twitter by following @Neurosurgery and @CouncilSNS and using the hashtag #Medicolegal.

Jason D. Stacy, MD
North Mississippi Medical Center
Tupelo, Miss.

AANS Neurosurgeon Spotlight: Winter 2020 – The Mind of a Neurosurgeon Part II

By AANS Spotlight, MedEd, Medical Liability, MentoringNo Comments

Articles in the latest issue of AANS Neurosurgeon: “The Mind of a Neurosurgeon” take on the daunting task of better understanding what makes us tick! Many of the best and brightest have graciously considered aspects of this question and shared their poignant thoughts:

The Case for Mindfulness and Compassion

James R. Doty, MD, FAANS

  • Focus Lost. Every moment in surgery can be critical, right to the very end.
  • Focus Regained. I am working blind, so I open my heart to a possibility beyond reason, beyond skill and I begin to do what I was taught decades ago, not in residency, not in medical school, but in the back room of a small magic shop in the California desert.
  • For some it manifests as forgetfulness. Others experience compassion fatigue. Some experience moral injury and completely lose their motivation to serve their patients. In the worst cases, as defined by the ICD-10, physician’s burnout results in a state of vital exhaustion.
  • Being able to apply mindfulness training and a self-compassionate attitude to my profession gave me permission to attend to my own health and well-being.

The Impact of Medical Review Panels

Jennifer Kosty, MD; Bowen Jiang, MD; Devon LeFever; Jared R. Broughman; Frederick White, MD; Katie O. Orrico, JD; Bharat Guthikonda, MD, FAANS

  • Between 1990 and 2010, the National Practitioner Data Bank estimated malpractice and liability claims from adverse surgical events to be over $1.3 billion.
  • The Medical Review Panel (MRP) and Patient’s Compensation Fund are completely self-funded by physician participants, filing fees and investment income.
  • Once initiated, the panel has a 180-day period to render a decision with three possible outcomes: (1) Evidence demonstrates breach of the standard of care; (2) Evidence does not demonstrate breach of the standard of care; or (3) A question of fact exists bearing on the issue of liability which does not require expert opinion and therefore the MRP cannot render a decision.
  • Although the MRP has largely been beneficial for Louisiana, not all states have had similar experiences.

Inspiring Diverse Minds: The Value of Online Mentorship

Tiffany Ejikeme; Jennifer A. Sweet, MD, FAANS

  • Mentoring has been shown to be the most important factor for medical students in their choice of a specialty.
  • One specific challenge to mentorship relates to diversity. I have not come across many neurosurgeons who look like me, a black woman.
  • Staff physicians must relate to their students beyond the academic scope to form more authentic and effective relationships.
  • Further complicating the mentorship equation is how the medical student experience has evolved with the advent of technology.
  • Supporting efforts like WINS’ online mentorship portal, will help foster and develop mentorship relationships for students around the world.

Alternative Mind: How Non-traditional Experiences Enrich Neurosurgical Training Part 2

Juliana C. Rotter, MD; Avital Perry, MD; Christopher S. Graffeo, MD

  • Advanced communication skills and training are a crucial skill brought to neurosurgery by those coming in with background in business, administration or leadership.
  • The military mindset has a number of enriching elements including discipline to prioritize mission first as well as creating routinized procedures for debriefing, preparation and review.
  • Taken together, the less-traveled pathways have the potential to improve communication, diversify the collective skillset, enhance leadership and maintain the essential focus on the needs of the patient.

 

A Year in review: Making Progress on Neurosurgery’s Legislative and Regulatory Agenda

By Advocacy Agenda, Congress, Health Reform, Medical Innovation, Medical Liability, Prior Authorization, UncategorizedNo Comments

As we come to the end of a decade and head into 2020, it is fitting to reflect on the progress that the American Association of Neurological Surgeons (AANS) and the Congress of Neurological Surgeons (CNS) have made in advancing organized neurosurgery’s legislative and regulatory agenda to ensure that neurosurgical patients have timely access to quality care. At the beginning of 2019, we set forth an ambitious agenda, and throughout the year, the AANS and CNS continued to make progress on achieving our health policy goals.

Some highlights:

  • Protect Patients’ Timely Access to Care. Prior authorization is a cumbersome process that requires physicians to obtain pre-approval for medical treatments or tests before rendering care to their patients. To protect patients’ timely access to care, as leaders of the Regulatory Relief Coalition, the AANS and the CNS collaborated with key champions in Congress — Reps. Suzan DelBene (D-WA); Mike Kelly (R-PA); Roger Marshall, MD, (R-KS); and Ami Bera, MD, (D-CA) — to introduce H.R. 3107, the Improving Seniors’ Timely Access to Care Act. With 156 sponsors at year’s end, this bill would help protect patients from unnecessary delays in care by streamlining and standardizing prior authorization under the Medicare Advantage program.
  • Improve the Health Care Delivery System. Narrow insurance networks restrict patient access to the physician of their choice and leave patients vulnerable to unanticipated medical bills. Working to improve the health care delivery system, the AANS and the CNS successfully advocated for the introduction of legislation to protect patients from unanticipated medical bills. The Protecting People from Surprise Medical Bills Act (H.R. 3502), and the Stopping The Outrageous Practice (STOP) of Surprise Medical Bills Act (S. 1531), would hold patients harmless and ensure that they would only be responsible for in-network cost-sharing amounts when out-of-network providers take care of them. Patients would also be kept out of the middle of payment disputes between health plans and providers, and a process for fairly reimbursing providers for their services would be established.
  • Support Quality Resident Training & Education. An appropriate supply of well-educated and trained physicians — both in specialty and primary care — is essential to ensure access to quality health care services for all Americans. Looming physicians shortages — by 2032, the nation faces a physician shortfall of between 46,900 to 121,900 — threaten this access to care. To help ease this shortage and to support quality resident training and education, the AANS and the CNS successfully advocated for legislation to increase the number of Medicare-sponsored residency training positions. The Resident Physician Shortage Reduction Act ( 348 / H.R. 1763), with a total of 185 cosponsors, would increase the number of available medical residency positions by 15,000 over five years.
  • Continue Progress with Medical Innovations. America has a long tradition of excellence and innovation in patient care, and neurosurgeons have been on the cutting edge of these advancements. However, due to the medical device excise tax, American medical innovation and patient care have been at risk. Working with our partners in the medical technology industry for the past decade, the AANS and the CNS have been advocating for Congress to repeal this tax. This year, with the passage of H.R.1865, the Further Consolidated Appropriations Act, 2020, Congress demonstrated its commitment to continuing progress with medical innovation by repealing this tax. President Trump signed the legislation into law (P.L. 116-94). This bill also included increased funding for biomedical research in the neurosciences. Finally, Reps. Diana DeGette (D-Colo.) and Fred Upton (R-Mich.) released their initial vision for their Cures 2.0 initiative, which aims to modernize insurance coverage policies and improve access to life-saving cures. Cures 2.0 would build on the original 21st Century Cures Act (P.L. 114-255), which aspires to advance medical research and foster a new era of medical innovations.
  • Fix the Broken Medical Liability System. Medical lawsuit abuse is driving up health care costs, and driving good doctors out of the practice of medicine, leaving patients without the care they need when they need it. Many doctors — particularly in high-risk specialties like neurosurgery — are cutting back on high-risk and life-saving services, relocating to states with more patient-friendly liability laws, retiring early or leaving the practice of medicine altogether. To help fix the broken medical liability system, as a leader of the Health Coalition on Liability and Access, the AANS and the CNS worked with leaders in Congress to introduce H.R. 3656, the Accessible Care by Curbing Excessive LawSuitS (ACCESS) Act, which is modeled after proven reforms that are in place in California and Texas. In addition, legislation to help ensure that physicians are available to take care of patients with medical emergencies is pending before the House and Senate — the Good Samaritan Health Professionals Act (S. 1350) and the Health Care Safety Net Enhancement Act (H.R.3984).

We still have our work cut out for us to continue advocating for sound health policy that improves patient care, but 2019 will go down as a year in which the AANS and the CNS made significant positive strides.

          

 

 

AANS and CNS Release 2017 Legislative and Regulatory Agenda

By Access to Care, Antitrust, Coding and Reimbursement, Congress, Drugs and Devices, Emergency Care, GME, Health, Health Reform, Healthcare Costs, HIT, IPAB, MACRA, MedEd, Medical Innovation, Medical Liability, Medicare, Quality ImprovementNo Comments

On February 14, 2017 the AANS and CNS released their 2017 legislative and regulatory agenda, which includes action items such as improving the health care delivery system, abolishing the Independent…

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