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COVID-19 Archives - Page 2 of 4 - Neurosurgery Blog

Practice Restructuring in the COVID-19 Era

By CNS Spotlight, COVID-19, Cross PostNo Comments

From time to time on Neurosurgery Blog, you will see us cross-posting or linking to items from other sources that we believe are relevant to our audience. We wanted to bring attention to this article from the Winter 2021 issue of Congress Quarterly titled “Considerations for Private Practice Groups in the Age of COVID.” Stacey Lang, an executive administrator at the University of Pittsburgh Medical Center and a volunteer with the Neurosurgery Executives’ Resource Value & Education Society, outlines both short-term and long-term considerations for practice restructuring in the COVID-19 era, including staffing, facility and scheduling matters.

According to a recently released American Medical Association survey, the average number of weekly office visits per provider fell by over 50%. In addition, while on average physicians experienced a 32% drop in revenue since February, approximately 20% saw reductions of 50% or more. Less than 20% of physicians reported no decrease in revenue. Given the duration of the pandemic thus far, it is difficult to remember what everyday practice was and to imagine that we will, at some point, return to normal, albeit a new normal.

To read the complete article, click here.

Editor’s Note: We encourage everyone to join the conversation online by using the hashtags #COVID19 and #Neurosurgery.

February 16, 2021
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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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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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Our Health Care Workers Are Struggling — That’s Why I Introduced Legislation to Help

By Burnout, Health, Work-Life BalanceNo Comments

As the husband of a physician, I like to say that issues affecting health care workers aren’t just dinner tables issues — they’re breakfast, lunch and dinner table issues. This has never been truer than it is during the current coronavirus crisis.

When the greater Chicago area was overrun with COVID-19 patients this past spring, my wife, an anesthesiologist, was among those on the front lines placing intensive care unit (ICU) patients on ventilators. She did so while wearing a welder’s mask that she purchased from a hardware store because there was simply not enough personal protective equipment (PPE) to go around. Our children and I could not have been prouder of her bravery, but we worried about her constant exposure to the virus and the pressures of being a frontline health care worker during a pandemic.

Although case numbers have come down in our area, the virus is far from quashed, and any amount of progress feels fragile. For many who served in hot spots like New York City in the early days of the pandemic — and those in areas currently experiencing surges, like Miami and Houston — navigating the emotional toll of being on the front lines has proven to be among the pandemic’s greatest challenges.

As with so many other areas of policy, the COVID-19 crisis has forced us to confront the ways we have failed as a nation to look out for the well-being of our health care workforce. Too many have struggled in silence for decades; now, they have been called to respond to a once-in-a-century public health crisis without an emotional safety net. It is for these reasons that I introduced the bipartisan Coronavirus Health Care Worker Wellness Act (H.R. 7255), along with my colleagues Reps. John Katko (R-N.Y.) and Frederica Wilson (D-Fla.). This legislation seeks to accomplish two goals:

  • First, the bill will authorize U.S. Department of Health and Human Services (HHS) to distribute grant funding to health care providers who wish to establish or expand programs dedicated to promoting the mental wellness of their workers on the front lines of COVID-19; and
  • Second, the bill will authorize a comprehensive, multi-year study on the issue of health care worker mental health and burnout, including an assessment of underlying factors, barriers to seeking and accessing treatment, implications for the health care system and patient outcomes, and the impact of the COVID-19 crisis.

Studies and events of the past several months have confirmed that many health care workers are indeed struggling with their mental health as a direct result of COVID-19. Consider the following:

  • Health care workers have witnessed death on an unprecedented scale, and social distancing orders have put them in the agonizing position of denying families access to their loved ones and notifying them of deaths over the phone;
  • With morgues overflowing, some hospitals have parked refrigerated trucks outside to store additional bodies;
  • Critical shortages of PPE in the spring forced health care workers to re-use equipment or go without it, and there is a fear that shortages could return if cases spike again this fall;
  • Over 135,000 health care workers have been infected with COVID-19 to date, and more than 600 have died;
  • Data from China — a country that experienced an acute outbreak much like our own in March and April — put startling figures on reported rates of depression (50.4%), anxiety (44.6%) and insomnia (34.0%) among frontline workers;
  • Another study conducted between March and May found that the average U.S. health care worker — not just those on the front lines — reported enough depressive symptoms to be considered clinically depressed;
  • Rates of post-traumatic stress disorder (PTSD) among frontline workers are expected to rival those among first responders to the 9/11 terrorist attacks; and
  • Lorna M. Breen, MD — an emergency room physician in New York City who contracted COVID-19 herself — tragically believed she had no choice but to take her own life amid the devastation.

As dire as the current situation is, the unfortunate truth is that burnout and mental health challenges were common among health care professionals long before the world had ever heard of SARS-CoV-2 — something that likely comes as no surprise to members of the neurosurgery community.

COVID-19 will, unfortunately, be with us for an extended period. Frontline workers needed our support back in March — not just with our words, but with Congressional action — and we failed to provide it. We simply cannot overlook this situation any longer, nor can we continue to ignore the importance of the long-term job satisfaction of our nation’s health care workforce. We must pass the Coronavirus Health Care Worker Wellness Act as soon as possible.

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 #PhysicianBurnout.

U.S. Congressman Raja Krishnamoorthi (IL-8)

September 11, 2020
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Lasting Change: Assessing the Potential Long Term Impact of COVID-19

By COVID-19, HealthNo Comments

“Real change, enduring change, happens one step at a time.”

Ruth Bader Ginsburg

Associate Justice, U.S. Supreme Court

The economic, medical, political and psychological tsunami unleashed by the COVID-19 virus is unlike anything we have seen in our lifetime. The traumatic disruption of 9-11 was limited in comparison to our current crisis. While impossible to include up to the minute statistics, already more than 15 million cases have been confirmed with at least 620,000 deaths, and U.S. unemployment is approximately 11%. Is it possible that any good will come of these months of tragedy and lock-down? What do we know about the immediate and longer-term consequences on us as humans, on the health care community and neurosurgery? I have been given the monumental task of trying to peer into that future as the Neurosurgery Blog’s focus on COVID-19 draws to a close.

Silver Linings: Our World

Today, the canals of Venice are clear, and dolphins have returned — an amazing and rapid transformation. During the pandemic lock-down, our environment improved dramatically with blue skies seen across India, air pollution around major cities visibly and measurably improved, leading to improved health, and images from space revealing stunning clarity. Beyond recognizing how reversible the damage to our physical world is, we have witnessed the very best of humanity in our communities. Touching stories have filled our news feeds:

These represent the many things individuals are doing every day to make the lives of those around them safer and more fulfilling.

To fill the void left by social distancing, many have become facile with video technology to provide essential human contact during long weeks of isolation. Religious services, theaters, concerts and more have rapidly adapted to provide their communities invaluable connection and engagement.

Silver Linings: Health Care and Neurosurgery

As grim headlines unfolded, the health care community united. Traditionally competitive institutions have reached beyond those boundaries to share expertise, resources and staff to provide the best care for patients. Necessary innovation has blossomed creating change that will survive beyond COVID-19 such as:

The Centers for Medicare & Medicaid Services (CMS) authorized payment for telemedicine services, with many private insurance companies following on their heels. This marks a crucial advance and should herald a new era of health care delivery. A world free of many of the inconveniences associated with a visit to the doctor — days off work, parking, travel, navigating complex hospital corridors — is no longer a figment of the imagination. Reimbursement for these services will drive technological innovation that will enhance the value and experience of these visits. While there will always be an essential role for the face-to-face appointment —especially in the surgical disciplines such as neurosurgery — and the importance of human touch, the provision of telemedicine care should be more comfortable and more convenient.

Neurosurgery stepped up and came together in many meaningful ways. Many of our national and international organizations, as well as neurosurgical publications, provided state of the moment information to connect us around the world. Neurosurgeons continued to keep their practices afloat to provide care to those with emergent conditions despite considerable risks to themselves and, by extension, their loved ones. Many stepped into roles of supporting other physicians overwhelmed by the sheer volume and acuity of COVID-19 patients. In contrast, others assumed leadership roles helping their hospitals and communities in many ways — designing systems for surge redeployment of staff and creating new operating room policies to enhance airflow. Each institution has found ways to protect their resident team while ensuring they continue to receive valuable education and feel fully supported during a time of great strain.

Not All Roses

Still, many vulnerabilities were revealed, and scars will be left from the crisis. Neurosurgery lost one of our most beloved colleagues when COVID-19 took the life of James T. Goodrich, MD, PhD. Questions arose, such as how could things as simple as masks, gloves and gowns become such a challenge to procure? Known health care disparities were shown to exist, likely reflective of such differences at every level of medical care, but poignantly and tragically demonstrated in COVID-19 related deaths, morbidity and availability of resources. This was further brought into the spotlight by the death of George P. Floyd, Jr. and the dramatic national response that followed. Finally, people learned it isn’t so glamorous or pleasant to wear a mask, as neurosurgeons have known our whole careers.

Lasting Change

Most meaningful change does evolve incrementally; however, cataclysmic events like the COVID-19 crisis instigate sudden and dramatic change. Given the potential for positive unintended consequences, here is my wish list (please add your own!) for enduring gifts we deserve from COVID-19:

  • A deep appreciation not only for the fragility of the world around us but also its capacity for resiliency — let us remain mindful of how all of our actions impact the earth, our health, and our fellow humans;
  • A new dawn of real innovation in medicine that builds new frontiers of access and engagement by leveraging the best of augmented intelligence and melding it with the personal touch that only humans can provide;
  • Restoration of travel because of all the good it brings but with a profound sensitivity on how to preserve the beauty of the natural and man-made world; and
  • A renewed and sustaining appreciation for the difficult work done by neurosurgeons and all physicians, along with their dedicated teams, to care for patients and their loved ones every day.

We thank our readers for following Neurosurgery Blog as it recorded the real-time impacts of the COVID-19 global pandemic. As the world emerges from these trying times, we invite you to continue the conversation on Twitter by following and using the hashtag #COVID19. With new therapeutics and promising vaccines, the glimmer of hope becomes stronger with each passing day.

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

July 24, 2020
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Aerosolization, Endonasal Surgery and the Neurosurgeon

By COVID-19, HealthNo Comments

Neurosurgeons never stop learning. As a result of the COVID-19 pandemic, previously obscure terms such as airflow and aerosolization — the dispersal of a substance such as medicine or viral particles in the form of an aerosol — have entered our regular lexicon. We can now readily identify which of our operating rooms has the highest airflow — usually the smallest room — and the standard for the minimum number of air exchanges per hour, which is at least 15.

COVID-19 has brought to light a new spectrum of difficulties for neurosurgeons. Of particular concern are increasing reports of significant morbidity and mortality among otolaryngologists in several countries that have been putatively linked to endonasal surgery. Patel and coworkers from Stanford University highlighted this issue in a letter to the editor in Neurosurgery. They urge precautions for endoscopic transnasal skull base surgery during the COVID-19 pandemic due to the concern that aerosol droplets coming from surgery may increase the possibility of infection of medical staff in the operating room.

In a reply, Huang and colleagues from Huazhong University of Science and Technology in Wuhan, China, were able to provide additional information regarding COVID-19 spread. They believe that compared to droplet transmission, contact transmission may be an equally important factor in transmission in medical workers and was ignored during the early stages of the pandemic due to lack of knowledge. They urge washing hands and cleaning all surfaces in patient units and living areas.

The authors also share that they have learned that intraoperative aspirators, protective clothing, N95 masks and face shields can provide sufficient protection to our medical staff in the surgery room. Huang and colleagues warn that the claim that endonasal surgery will increase the possibility of infection of medical personnel in the operating room might provoke unnecessary anxiety toward endonasal endoscopic procedures based on an anecdotal statement.

Patel and collaborators in their rebuttal accept some of these arguments but point out that emerging evidence also points towards a high viral load within the nasal cavity. When performing endoscopic surgery, while working in and through this corridor, surgical maneuvers can aerosolize mucus particles along with the virus.

In a convergence of the scholarly debate, both groups arrive at similar recommendations with an emphasis on preoperative COVID-19 testing, which should be performed whenever possible. Reduced contact with infected patients and the use of personal protective equipment — including N95 masks, face shields and protective clothing — should be employed for all endoscopic cases and all involved personnel. Powered air-purifying respirator use should be encouraged in cases of symptomatic COVID-19-positive patients needing emergent endonasal surgery. A negative pressure operating room is also recommended. Elective endoscopic transsphenoidal surgery should be delayed, and consideration should be given to transcranial approaches for certain locations where possible.

We share the optimism for the future of endonasal surgery as more data comes to light to guide best practices that will maximize its benefit for our patients while minimizing potential risks to surgeons and other operating room personnel.

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 and using the hashtag #COVID19.

Clemens M. Schirmer, MD, PhD, FAANS, FAHA
Chair, AANS/CNS Communications and Public Relations Committee
Geisinger
Wilkes Barre, PA

July 13, 2020
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AANS Neurosurgeon Spotlight: The State of Neurosurgical Education

By AANS Spotlight, Burnout, COVID-19, GMENo Comments

Recent global circumstances have had considerable effects on neurosurgery. In the latest articles from AANS Neurosurgeon, the official socioeconomic publication of the American Association of Neurological Surgeons (AANS), authors discuss the state of neurosurgical education. Practices have taken steps to not only adapt to a multitude of changes due to the COVID-19 pandemic, but to thrive among them, while helping their patients do the same. Browse the Education issue for a scientific, artistic and realistic view from those tasked with providing and navigating valuable educational experiences during a time when there is no such thing as “normal.”

Article Spotlight

This Crisis is an Opportunity
Lola B. Chambless, MD, FAANS

Dr. Chambless explains how the pandemic has provided an unprecedented opportunity to study, learn and reform.

A Combined Spine Surgery Fellowship
Jason Savage, MD ꟾ Michael P. Steinmetz, MD, FAANS

Discover the makings of a successful spine fellowship – strong leadership, constant re-evaluation and a collaborative surgeon group.

Pen versus Penfield: A Proposed New Training Modality for Neurosurgery Residents
Erin N. D’Agostino, MD

Dr. D’Agostino describes how art “can serve a role in surgical skill building, learning and teaching of anatomy, patient education and combating burnout.”

Read More

Follow @aansneurosurg on Twitter, Instagram and like AANS Neurosurgeon on Facebook!

July 10, 2020
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Neurosurgeons Launch Campaign to Protect Patient Access to Care

By Access to Care, COVID-19, Guest Post, Health Reform, MedicareNo Comments

Our health care system is under extraordinary pressure. The COVID-19 pandemic has created an uncertain financial future for health care professionals. And now, coming on the heels of this devastating pandemic, Medicare is poised to implement drastic cuts. These cuts threaten patients’ access to timely surgical care and may impact the quality of life for the people neurosurgeons care for every day. To help policymakers and the public understand how these payment cuts will hurt patients and their neurosurgical care teams, on June 18, the American Association of Neurological Surgeons (AANS) and the Congress of Neurological Surgeons (CNS), along with 10 other national surgical associations, officially launched the Surgical Care Coalition (SCC).

The coalition, which represents more than 150,000 surgeons, was formed to stop these Medicare cuts to protect patients, improve their quality of life and ensure that our nation’s seniors have access to the neurosurgeon of their choice when they need life-saving neurosurgical care. Specifically, the SCC is worried about new Medicare payment policies for office and outpatient visits that the Centers for Medicare & Medicaid Services (CMS) will implement in January 2021. Changes to these visit codes — also known as evaluation and management (E/M) codes — will reduce payments for surgical care, which may lead to reduced access to care for older Americans. Working together, the coalition is putting this issue on the nation’s agenda and is urging Congress to pass legislation that will prevent these payment cuts.

To learn just how fragile our health care system is, the SCC recently commissioned a survey of more than 5,000 surgeons. According to this study, surgical practices are facing severe financial distress due to the COVID-19 pandemic. While the cuts were announced before the pandemic, with the combined impact of the planned CMS cuts and the economic challenges due to COVID-19, surgeons and hospitals will face difficult decisions to keep surgical practices afloat. For neurosurgeons, the survey found that even before the CMS cuts take effect:

  • More than one-half (54%) of respondents are concerned that they could be forced to shut down their practice, limiting choice and access to neurosurgical care;
  • Three-quarters (74%) of neurosurgeons are concerned about the finances of their practice, and to keep the doors open, 38% have cut their own salary, and one-quarter (24%) have taken on debt as a result of COVID-19; and
  • In the face of declining revenues, 86% of respondents are worried that they will have to cut employee’s salaries and 76% fear that they may have to permanently layoff employees.

In announcing the SCC initiative, John A. Wilson, MD, FAANS, president of the AANS, noted that “Neurosurgeons take care of critically ill patients who suffer from painful and life-threatening neurologic conditions such as traumatic brain injury, brain tumors, debilitating degenerative spine disorders and stroke, and without timely neurosurgical care, our patients can face permanent neurologic damage or death. He added, “The planned cuts to Medicare payments will further stress a healthcare system critically affected by the pandemic crisis and may negatively impact Medicare beneficiaries’ access to care.”

Echoing his remarks, Steven N. Kalkanis, MD, FAANS, president of the CNS, stated, “It is essential that policymakers understand how these payment cuts may impact access to surgical care. COVID-19 has placed an unprecedented strain on our health care system, and additional Medicare payment cuts will not only threaten timely access to quality care but will also stress an already fragile health care system.”

Our seniors need to take comfort in the fact that a neurosurgeon will be there if and when they ever require neurosurgical care. Medicare cuts hurt patients, and the Surgical Care Coalition is fighting to prevent payment cuts that threaten patients’ timely access to neurosurgical care.

Editor’s Note: Neurosurgery Blog encourages you to follow the coalition on Twitter and LinkedIn, and we invite you to join the conversation at #CutsHurtPatients.

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

June 24, 2020
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Reflecting on COVID19, the Death of George Floyd and the Need for Change

By COVID-19, Equity, Social JusticeNo Comments

“I want to touch the world.”
George Perry Floyd, Jr.

We are living in trying and turbulent times in our country. A global pandemic has claimed the lives of more than 100,000 people across America and has threatened to overwhelm our health care systems in some of the worst affected areas. On top of this health crisis, we are now facing the greatest civil unrest our country has experienced in over 50 years in response to a recent series of tragic deaths of black men and women — the cataclysmic event being the deplorable death of George P. Floyd, Jr. while in police custody.

While we look to our politicians for the political answers that will heal the strife in our country, we are all struggling with our personal feelings and response to these events. It has been extremely heartening, however, to see the expression and renewed commitment to inclusion and diversity, particularly within the medical community.

As voices cry out across the world underscoring the systemic problems of racism and inequality, the American Association of Neurological Surgeons (AANS) and the Congress of Neurological Surgeons (CNS) have joined the chorus speaking out against all forms of discrimination and acts of violence — particularly that which is driven by intolerance and hatred. We reaffirm our commitment to inclusion and diversity. We reflect on the past and the messages of Dr. Martin Luther King, Jr. and Robert F. Kennedy. And we listen to our Black and Brown colleagues who provide a uniquely pertinent perspective on these issues, and we are thankful for their leadership and willingness to speak out.

We hope our readers will be inspired by the words of our colleagues from across the medical profession, which are reposted below in this piece. Millions around the world were horrified in disbelief at the killing of an unarmed man in police custody. As individuals and together as a society, we owe it to George Floyd and countless others to not let his death be in vain and to work to seek lasting change to stamp out racism, inequality and violence. We encourage you all to engage your patients, your colleagues and your communities in discussions as to how we can help heal our country and care for all who need us, including our most vulnerable.

In addition to the above message from the AANS and CNS, neurosurgeons and neurosurgical organizations spoke out.

A group of Black neurosurgeons who came together to publish an OpEd pointed out that as neuroscientists and surgeons, they see firsthand the effects of neurotrauma on those subjected to violence at especially alarming rates in the Black community. From the debilitating effects of blunt and penetrating trauma to the brain and spine to the “intangible neuropsychological effects stemming from fearing for one’s life on a daily basis,” there “is a slow but inevitable erosion of the state of health amongst Black people… This has culminated in a public health crisis shortening not only the lives of too many too early but diminishing the quality of life of those who remain to bear it.”

Reflecting on the shocking video depicting the death of George Floyd, neurosurgeon Fredric B. Meyer, MD, FAANS, the Juanita Kious Waugh Executive Dean for Education of the Mayo Clinic College of Medicine and Science and dean of the Mayo Clinic Alix School of Medicine, wrote to all medical students, residents and fellows. In his letter, Dr. Meyer reminded us “that although our country has made tremendous advances in civil and human rights, we all have significant work to do on so many levels to fight hatred, bigotry, and violence.” He recalled how Bobby Kennedy was one of his family’s heroes and how, as U.S. Attorney General, he was a strong advocate for civil rights. Dr. Meyer went on to note that in this time of terrible strife, anger, mistrust and hatred in our country, he is reminded of a powerful speech that Bobby Kennedy gave spontaneously on the back of a pickup truck when he learned of the assassination of Martin Luther King, Jr. He, along with his brother, President John F. Kennedy, and Dr. King, were all assassinated for the truth they spoke about human decency, civil rights, and a humane society. Dr. Meyer commends to the medical community the YouTube video of Bobby Kennedy announcing Dr. King’s death and to also listen to his speech on humanity, mindless violence and affirmation. His words are as relevant today as they were decades ago, and, as Dr. Meyer aptly stated, it is distressing that fifty years later, the same hatred that killed Dr. King continues to be pervasive in our society.

Leaders of the Society of Neurological Surgeons (SNS) — M. Sean Grady, MD, FAANS, president; Karin M. Muraszko, MD, FAANS, past-president; and Nathan R. Selden, MD, PhD, secretary — wrote to SNS members, neurosurgery department chairs and neurosurgical residency directors. In their message, they called on “educators to exemplify the highest moral and ethical standards for our trainees.” They noted that as educators and leaders in neurosurgery, we must ensure “that the American principles of fair and equal treatment for all are the bedrock of our Neurosurgical community.” Reaffirming a commitment to be “an inclusive organization reflective of the ‘higher’ principles,” they pledged “to grow and adapt and to listen to those we educate and those we serve. Although we may not have walked in their shoes, we will remain open to the knowledge and experience of every colleague and trainee and will respect and acknowledge them for their character and skills rather than for their appearance. Like our society, we believe we can continue to grow towards a more perfect union of our ideals and the reality in which we live,” and to strive together to reach higher ground.

The AANS/CNS Cerebrovascular Section, the Society of NeuroInterventional Surgery (SNIS) and the Society of Vascular & Interventional Neurology (SVIN) joined together to issue a statement acknowledging the difficult and disturbing times that the country is experiencing. These neurovascular organizations pointed out that “acts of violence and racism cause psychosocial stress that leads to poor well-being and cerebrovascular health, especially for communities of color. Given that heart disease and stroke are the leading causes of death for communities of color, our organizations are extremely disturbed by violent acts that cut to the core of the lives in our communities. We denounce the incidents of racism and all violence that continue to ravage our communities.”

Beyond the neurosurgical community, leading national medical organizations also spoke out.

The American College of Surgeons stated that it “stands in solidarity against racism, violence, and intolerance, noting that its “mission is to serve all with skill and fidelity, and that extends beyond the operating room. Racism, brutal attacks, and subsequent violence must end. We will help any injured, and we will use our voice in support of the health and safety of every person.”

Leaders from the American Medical Association (AMA) reminded us that AMA policy “recognizes that physical or verbal violence between law enforcement officers and the public, particularly among Black and Brown communities where these incidents are more prevalent and pervasive, is a critical determinant of health and supports research into the public health consequences of these violent interactions.”  The AMA continued, noting that the “disparate racial impact of police violence against Black and Brown people and their communities is insidiously viral-like in its frequency, and also deeply demoralizing… Just as the disproportionate impact of COVID-19 on communities of color has put into stark relief health inequity in the U.S.”

Finally, the Association of American Medical Colleges (AAMC) pointed out that “the coronavirus pandemic has laid bare the racial health inequities harming our Black communities, exposing the structures, systems, and policies that create social and economic conditions that lead to health disparities, poor health outcomes, and lower life expectancy.” The AAMC statement goes on to address how the brutal and shocking deaths of George Floyd, Breonna Taylor and Ahmaud Arbery “have shaken our nation to its core and once again tragically demonstrated the everyday danger of being Black in America.” Issuing a call to action, the AAMC expresses that “as healers and educators of the next generation of physicians and scientists, the people of America’s medical schools and teaching hospitals bear the responsibility to ameliorate factors that negatively affect the health of our patients and communities: poverty, education, access to transportation, healthy food, and health care.”

The AANS and CNS echo this call to action and concur that we “must move from rhetoric to action to eliminate the inequities in our care, research, and education of tomorrow’s doctors.”

Editor’s Note: Neurosurgery Blog invites you to join the conversation for social change at #WhiteCoatsforBlackLives and #ChangeTheSystem.

 

John A. Wilson, MD, FAANS
President, American Association of Neurological Surgeons
David L. and Sally Kelly Professor and Vice-Chair of the
Department of Neurosurgery, Wake Forest School of Medicine

 

 

Steven N. Kalkanis, MD, FAANS
President, Congress of Neurological Surgeons
Chief Executive Officer, Henry Ford Medical Group
Detroit, Mich.

June 10, 2020
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COVID-19 and Prevalence of Stroke: Making Sense of the Data

By COVID-19, Health, StrokeNo Comments

The current COVID-19 pandemic has been a singular event with far-reaching societal and medical ramifications. The enormity of the crisis and the alacrity of its spread across the globe has led to a rapidly evolving understanding of the disease. Current knowledge of the pandemic and the effect of the virus on the human body may become obsolete by week’s end. The COVID-19 crisis’s impact on the care of stroke patients is emblematic of these issues. Over the past few months, several data points have emerged that have been interpreted in divergent ways.

For example, early on, there was speculation from New York City — one of the regions hardest hit by COVID-19 — that COVID-19 was associated with an increased risk of fatal ischemic stroke in young adults. Several physicians from New York authored a report of their experience with five stroke patients infected with SARS-CoV-2, aged 33 to 49. This study received significant attention in both the press and academic journals. We currently understand COVID-19 to be a mild disease in most people. However, occasionally it progresses to a more severe process, including acute respiratory distress syndrome (ARDS), multi-organ dysfunction, cytokine storm, inflammation, coagulation and death. Coagulopathy and vascular endothelial dysfunction have been proposed as complications of COVID-19. Although the authors shed light on the clinical characteristics of young adults with these two pathologies, they were not able to explain the possible association between stroke and COVID-19 fully.

On the contrary, several researchers have indicated a decreased incidence of ischemic stroke across the world during the COVID-19 pandemic. The drop in the rate of stroke presentations has been so dramatic that various medical societies and advocacy groups have issued statements urging patients not to delay stroke care out of fear of being exposed to SARS-CoV-2, the virus causing COVID-19. While this a plausible explanation for the decreased incidence of stroke during the height of the pandemic, we believe it may be too early to tell whether this is, in fact, the case.

Another data point suggests that patients are seeking care for stroke symptoms in a delayed fashion, resulting in suboptimal outcomes. Most stroke experts have attributed this phenomenon of “vanishing strokes and heart attacks” to the unwillingness of patients to be exposed to COVID-19 in an already overwhelmed emergency room. By contrast, researchers from Italy have hypothesized a pathophysiologic mechanism behind the decreased incidence of stroke in COVID-19 patients based on the controversial role of Interleukin 6 (IL-6) — a protein involved in inflammation — in stroke. There is experimental evidence that IL-6 — which is elevated in patients with more severe forms of COVID-19 — has a neuroprotective effect and enhances angiogenesis (formation of new blood vessels). Another possible explanation offered is the thrombocytopenia (low platelet counts) encountered in patients even with mild cases of COVID-19, as low platelet levels may prevent the formation of large clots in the intracranial circulation. Lastly, the widespread mitigation measures, which have minimized the prevalence of influenza in the community, may have attenuated the typical negative impact of the flu on cardiovascular disease and stroke. Further research into the effects of these various associations is warranted.

In these times of crisis, we remain dedicated to offering the highest level of care for stroke patients focusing on the following principles:

  • Clear identification of Comprehensive Stroke Centers (CSCs), which can offer all stroke-related services even during the pandemic;
  • Information for emergency medical services and the public that CSCs will be protected and will remain fully operational during crises; and
  • Education for health professionals and the public — especially those who are at high risk of stroke — leading to early recognition of stroke symptoms and contacting emergency medical services immediately to be taken to a CSC to avoid significant delays in transferring patients between hospitals.

A full picture of how COVID-19 influences the phenotype, incidence, and demographics of acute ischemic stroke patients has yet to emerge and may not for many months. Until then, it remains paramount to focus on measurable outcomes and continue to leverage the proven components of our stroke system of care to the benefit of our patients. Education — as was emphasized throughout May’s National Stroke Awareness Month — needs to continue and must be the cornerstone of engagement of the health care system with the public to reassure that we are able and ready to take care of our patients safely.

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 and using the hashtag #COVID19.

Kimon Bekelis, MD
Vice-chair, AANS/CNS Communications and Public Relations Committee
Director of the Stroke & Brain Aneurysm Center and co-director of the Neuro ICU at Good Samaritan Hospital Medical Center
Chairman, Neurointerventional Services at Catholic Health Services of Long Island
Director, Population Health Research Institute of New York at CHSLI
Assistant Professor, The Dartmouth Institute for Health Policy and Clinical Practice
West Islip, N.Y.

Clemens M. Schirmer, MD, PhD, FAANS, FAHA
Chair, AANS/CNS Communications and Public Relations Committee
Geisinger
Wilkes Barre, Pa.

June 8, 2020
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