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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

January 11, 2021
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Diversity in Neurosurgery: Forcing Change Leads to Greater Success

By Career, Guest Post, Women in NeurosurgeryNo Comments

Should we take a stand to increase diversity? Yes! As neurosurgeons, we should talk about diversity in neurosurgery. If we don’t urge, even force change, it will not happen, or it will happen unbearably slowly. One hundred years into the history of neurosurgery, only 5% of all board-certified neurosurgeons are women. African-Americans are also underrepresented. The Association of American Medical Colleges (AAMC) calculates that African-Americans represent 4% of all active neurosurgeons in the U.S.

Why does diversity matter? There is a compelling business case to be made for supporting equity and striving for inclusion. Companies with 30% or more women in the C-suite have reported higher profits than companies without women in their leadership team. A diverse workforce brings diverse perspectives, experiences and skills to the table, and it pays off.

The benefits of diversity aren’t limited to the corporate world. Diversity of opinion leads to better outcomes and fosters innovation and creativity across a variety of disciplines. The diversity of our patients should be reflected in the physicians who provide them care. Although we are all the same under the scalpel — cultural, religious, socioeconomic, ethnic and racial differences play a significant role in patient-physician relationships and impact patient satisfaction, patient compliance and health care outcomes. As surgeons, we need to continually enhance our awareness of and ability to manage our biases and racial/ethnic identity. We need to apply our critical appraisal skills, honed to perfection, to treat our seriously ill patients, to recognize that both explicit (conscious) and implicit (subconscious) biases can stand in the way of increased diversity and inclusion and prevent some of our patients from having the best outcomes possible.

Although neurosurgery has a more diverse group of residents than ever before, we need to work hard to retain these residents long-term and make sure they succeed. Female gender is one of the leading factors associated with burnout and attrition in our specialty. This is not due exclusively to the long and unpredicted work schedules related to the specialty. Microaggressions, lack of collegial relationships and tolerance of unacceptable behavior by faculty should be considered as well. These insidious factors can fester in a workplace culture because of a lack of mechanisms and implicit barriers for reporting, such as fear of shame, retaliation, or not advancing. Many minorities experience overt and implicit forms of discrimination. This may be exhibited openly from patients who mistake someone for a nurse of a janitor or refuse care from a minority physician. Sadly, this can come in more hidden ways from peers who won’t put a resident in a challenging case because of race or gender.

It is not enough to focus on micro-level interventions — we also need to look at organizational structures and attitudes that push women and minorities away from neurosurgery. It has been shown that interventions focused on cultural competencies in health care organizations improved the hospital’s diversity climate. These interventions have focused, among other aspects, on diversity attitudes, implicit bias and racial/ethnic identity status. However, too many health care organizations and departments approach diversity with a sense of tokenism instead as a business imperative and driver of strategy.

In his 2004 bestseller, “Moneyball,” Michael Lewis wrote: “What begins as a failure of the imagination ends as a market inefficiency: when you rule out an entire class of people from doing a job simply by their appearance, you are less likely to find the best person for the job.” All medical specialties want to attract the best and brightest young people. Diversity strengthens neurosurgery. Attracting people with different strengths and backgrounds to our profession can help unleash new sources of talent and creativity that can only benefit our profession and our patients.

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 using the hashtag #WomenInNeurosurgery and #CelebratingWINSat30.

Martina Stippler, MD, FAANS, FACS
Beth Israel Deaconess Medical Center
Boston, Mass.

January 8, 2021
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The Use of Social Media in Addressing Gender Disparities in Neurosurgery

By Career, Guest Post, Healthcare Social Media, Women in NeurosurgeryNo Comments

The importance of social media in neurosurgery, and medicine in general, has increased significantly over the past several years. As searched on PubMed, academic publications that include the search terms “social media neurosurgery” have increased over the last 10 years. Through various social media platforms, neurosurgeons can participate in educational endeavors, share scientific findings, build their brand and collaborate with others in the field despite geographical distance. The interactions that social media offers also provide an opportunity to network — to find mentors, role models and even friends outside one’s local academic and geographic environment.

A recent article by Norton et al. in the Lancet Neurology hypothesized that social media could address the gender gap in neurosurgery. As stated by Jamie S. Ullman, MD, FAANS, FACS, in a recent Medscape article, 12% of residents in neurosurgery are female, but only 5% of practicing neurosurgeons are women. Social media platforms allow females to identify other women in the field and provide a way to interact with these colleagues. Traditionally, a primary venue for networking has been conferences, such as the annual meetings of the American Association of Neurological Surgeons (AANS) and the Congress of Neurological Surgeons. While these meetings provide opportunities to meet others in the field, they can be daunting for a young neurosurgeon, particularly a woman, as most attendees and speakers are male. The internet is easily searchable — undergraduates, medical students and residents can identify females in all levels of academic neurosurgery, including multiple chairwomen. Using social media platforms, interacting with other women is straightforward and often less daunting than doing so in person. Organizations such as Women in Neurosurgery (WINS) can promote and amplify women’s voices in the field and bring attention to challenges unique to female surgeons. Seeing that other women have overcome these challenges to become faculty, full professors and the president of the AANS can offer encouragement and may prevent attrition.

Social media’s utility in addressing the gender imbalance does not apply just to women but to all minorities who have difficulty seeing themselves in a field with so many challenges. Identifying someone of similar gender, race, ethnicity or background who has achieved one’s desired goal makes it easier to believe that it is possible. Although academic interest regarding gender and neurosurgeons has increased — as evidenced by the number of articles devoted to this topic — the same cannot be said for other underrepresented groups. Literature searches in PubMed for “diversity,” “minority” or “underrepresented” in combination with neurosurgery did not identify articles assessing the impact of any minority status on entering neurosurgery, neurosurgical success or attrition. This may be due to the small number of minority practitioners.

Social media may be particularly useful for establishing connections within groups that are underrepresented in neurosurgery, and medicine in general. Our specialty can only improve as its practitioners reflect the diversity of our patients and as we continue to attract the best and brightest minds from all available backgrounds, demographics and socioeconomic groups.

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 using the hashtag #WomenInNeurosurgery and #CelebratingWINSat30.

Angela M. Richardson, MD, PhD
Skull Base and Cerebrovascular Fellow
University of Wisconsin – Madison
Madison, Wisc.

 

 

Sheri Dewan, MD, MS, FAANS
Northwestern University Feinberg School of Medicine
Chicago, Ill.

January 4, 2021
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Women in Neurosurgery — A Legacy of Achievement and Breaking Barriers

By Career, Guest Post, Women in NeurosurgeryNo Comments

The past century has demonstrated tremendous progress in all disciplines of medicine. Parallel to this progress, and often a direct contributor to breakthroughs and achievements, has been the increasing role women have played in the profession. Neurosurgery is no exception. Although their ranks are small, especially compared to other specialties, the women of neurosurgery have played an outsized role in its rise as a specialty in the last hundred years.

The first major female contributor to the specialty was Louise Eisenhardt, MD. Dr. Eisenhardt had a unique and close working relationship with Harvey W. Cushing, MD, who is regarded as the father of modern neurosurgery. Dr. Eisenhardt was considered Dr. Cushing’s “right hand.” Before deciding to go to medical school, she began work in 1915 as an editorial assistant for Dr. Cushing. She continued to work for him while enrolled at Tufts University School of Medicine. Dr. Eisenhardt later rejoined Dr. Cushing as a neuropathologist and served as his surgery associate from 1928 to 1934, making on-the-spot diagnoses of tumors and tissues as Dr. Cushing removed them. While continuing to make pathologic diagnosis of tumor tissues, she kept a cumulative case log, co-authored papers with Dr. Cushing and taught neuropathology at Tufts. In 1938, Dr. Eisenhardt became the curator of the Yale University Brain Tumor Registry, which she and Dr. Cushing established. In 1944, she became the first Editor of the Journal of Neurosurgery — the official journal of the American Association of Neurological Surgeons (AANS) — and remained in that role for 22 years. From 1938-1939, Dr. Eisenhardt served as the first female president of the AANS (formerly known as the Harvey Cushing Society).

Over the years, other female neurosurgeons continued to expand the role of women in the specialty and made significant impacts in the field of neurosurgery. In 1986, Frances K. Conley, MD, MS, FAANS (L), became the first female to be appointed to a full tenured professorship of neurosurgery at a medical school in the U.S. In 1991, she made national headlines when she announced her intention to resign her tenured position as a neurosurgery professor at Stanford University Medical School in protest against the sexist attitudes of a male colleague who had recently been promoted. In 1998, her book Walking Out on the Boys was published, in which she recounted her experiences as a female surgeon and the sexism within the medical profession.

Ruth Kerr Jakoby, MD, FAANS (L), became the first female diplomate of the American Board of Neurological Surgery (ABNS) in 1961. In addition to her many other accomplishments, she served as president of the Washington Academy of Neurosurgery in 1972. In 1986, she became the first female neurosurgeon to become a lawyer. In 1981, Alexa Irene Canady, MD, FAANS (L), became the first African American female in the U.S. to become a neurosurgeon. She was also the recipient of two honorary doctorate degrees and was inducted into the Michigan Woman’s Hall of Fame in 1989.

In recent years female neurosurgeons have risen to the very top ranks of the specialty. In 2005, Karin M. Muraszko, MD, FAANS, became the chair of the University of Michigan Department of Neurosurgery, making her the first woman to chair an academic neurosurgical department in the United States. She also became the first female appointed as a director of the ABNS. In 2018, Odette Harris, MD, MPH, FAANS, obtained a tenured neurosurgery professor position at Stanford University School of Medicine, making her the first Black female to do so in the U.S. From 2018-2019, Shelly D. Timmons, MD, PhD, FAANS, was the first female neurosurgeon to serve as AANS president and the second female to rise to this position — 79 years after Dr. Eisenhardt. In 2019, Dr. Timmons also became the chair of the Department of Neurosurgery at the University of Indiana.

Thankfully, the upward trend of women in neurosurgery continues. According to the ABNS, 7.4% of the 6,069 active diplomates are women, and 16% of the 1,489 neurosurgery residents are women. These percentages are expected to rise as more women enter neurosurgery training programs. This promises to make the second century of our specialty full of even more notable breakthroughs and achievements.

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 using the hashtag #WomenInNeurosurgery and #CelebratingWINSat30.

Disep I. Ojukwu, MD, MBA, MPH
St. George’s University School of Medicine, Class of 2019

 

 

 

Laura Stone McGuire, MD
University of Illinois College of Medicine at Chicago
Neurosurgery Resident

November 25, 2020
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Progress Incremental: Understanding Sexual Harassment in Neurosurgery

By Career, Guest Post, Women in NeurosurgeryNo Comments

Under the table, his hand landed uncomfortably high on my thigh. Our conversation had drifted from our mutual interests in molecular biology research of brain tumors to books and music. Until that moment, I had felt really positive about our connection. It was 1984, and my infatuation with neurosurgery had led me to try and break into an overwhelming male subspecialty. I knew it would take something special to convince a program to make the leap and accept a woman. Throughout the lavish dinner event for the visiting resident applicants, I had foolishly thought, perhaps this was such an opportunity. When the hand landed, the conversation abruptly changed, and the senior faculty leaned very close and, with an unmistakable leer, said, “I would really love to help you become the first woman in our residency program. Shall we make those plans later tonight?”

Somehow, I managed to secure a residency training position in neurosurgery despite the odds and for the last four decades have navigated my training, clinical growth, academic advancement and rise in national leadership positions. Fortunately, I never again encountered such a blatant attempt for someone in a powerful position to coerce me into a sexual encounter. Still, there certainly were many times when I experienced other forms of sexual harassment. As is typical, for years, I said nothing — even to close friends or family — because somehow I felt “responsible” or else feared the consequences. All this time, I blindly assumed this was only happening to me and because I lived in a male-dominated surgical specialty.

Slowly over time, I became aware that I was not alone, and my experiences were similar to others. Unfortunately, others experienced far worse. (See Table 1). Those of us in the first wave of women in neurosurgery — training in the 1970s to early 1990s — naively hoped that our increasing numbers, sheer presence and leadership positions would lead to change. We had hoped that such behavior belonged only to the past. Sadly, we realized that was not the case.  When those efforts seemed ineffective, many of us quietly tried to rally neurosurgical leadership around efforts to try and improve the situation. Yet we were often met with disbelief there was a real problem.

When the #MeToo movement hit the media, however, many in neurosurgery recognized our potential vulnerability. And in 2018, the One Neurosurgery Summit established the Neurosurgery Professionalism Taskforce (NSPT). Under the leadership of James T. Rutka, MD, PhD, FAANS, and Karin M. Muraszko, MD, FAANS, the goal of the NSPT was to provide a comprehensive report on policies and recommendations regarding sexual harassment in neurosurgery. While the NSPT undertook many activities, one major initiative was the creation and administration of a survey to assess the depth and breadth of sexual harassment across neurosurgery.

I am proud to have co-authored the manuscript Toward an Understanding of Sexual Harassment in Neurosurgery published in the Journal of Neurosurgery. I genuinely believe it is a huge step forward for our specialty and part of slow but meaningful incremental progress. (See Table 2). The information gleaned from the survey, and the recommended strategies are important and can also serve all of medicine — especially those traditionally male-dominated specialties.

As the saying goes, “we have come a long way, baby,” as we celebrate 100 years of women’s right to vote in the U.S., the 30th anniversary of the Women in Neurosurgery Section (WINS) and now the publication of this landmark article. I hope this means no future neurosurgical residents — of any gender, race or sexual preference — will face the serious challenges of harassment that I and too many others have over many years. I remain ever hopeful.

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 using the hashtag #WomenInNeurosurgery and #CelebratingWINSat30.

Deborah L. Benzil, MD, FAANS, FACS
Cleveland Clinic, Vice-Chair, Neurosurgery
Cleveland, Ohio

November 12, 2020
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Honoring Those Who Have Served

By Military Faces of NeurosurgeryNo Comments

Each year on Veterans Day, the American Association of Neurological Surgeons (AANS) and the Congress of Neurological Surgeons (CNS) pay tribute to the contributions of the many military neurosurgeons who have made significant contributions and sacrifices. Whether on the battlefield, in the operating room or research lab, neurosurgeons have served our country with distinction and grace throughout history.

ICYMI, Neurosurgery Blog has featured many of these stories, and we encourage our readers to take a trip down memory lane. Read how former AANS president Roberto C. Heros, MD, FAANS(L), volunteered for the ill-fated Bay of Pigs invasion. Remember the horrors of the Vietnam War, as seen through the eyes of Patrick J. Kelly, MD, FAANS(L), while he was stationed in Da Nang during the bloodiest year of that conflict. Learn how neurosurgeons, like COL (ret) Rocco A. Armonda, MD, FAANS, have taken their skills from the operating room into the battlefield. Recall the recent efforts of the U.S. Comfort and Mercy, and how neurosurgeons came to the aid of Los Angeles and New York City as COVID-19 stressed the hospital ecosystem in the early days of the pandemic.

Thank you to these and all other veterans who have served our nation with selflessness and dignity to protect the freedoms we have all come to take for granted. Your service can never be honored enough. Happy Veterans Day, one and all.

November 11, 2020
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Twenty years from now you will be more disappointed by the things that you didn't do than by the ones you did do. So throw off the bowlines. Sail away from the safe harbor. Catch the trade winds in your sails. Explore. Dream. Discover.

Deborah L. Benzil, MD, FAANS, FACS
November 9, 2020
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