AANS Bulletin A quarterly publication of The American Association of Neurological Surgeons Michael L.J. Apuzzo, MD, Editor Susan A. Nowicki, APR, Staff Editor Tony Loster, CGCM, Production Manager Jennifer Lazzara, Graphic Designer Volume 6 • Number 2 Spring 1997 1996–1997 Officers and Directors J. Charles Rich, Jr., MD, President Edward R. Laws, Jr., MD, President-Elect Articles Russell L. Travis, MD, Vice-President Martin H. Weiss, MD, Secretary 15 AANS and CNS Launch New Joint Communications Stewart B. Dunsker, MD, Treasurer Program Sidney Tolchin, MD, Past-President Arthur L. Day, MD, Director-At-Large 21 NEUROSURGERY ON-CALL™ Continues to Expand Roberto C. Heros, MD, Director-At-Large Services A. John Popp, MD, Director-At-Large R. Michael Scott, MD, Director-At-Large William Shucart, MD, Director-At-Large 23 ACS Board of Regents Holds Winter Meeting John A. Kusske, MD, SW Regional Director P. Robert Schwetschenau, MD, NW Regional Director Herbert M. Oestreich, MD, NE Regional Director Donald D. Sheffel, MD, SE Regional Director Stanley Pelofsky, MD, JCSNS Liaison Karin M. Muraszko, MD, Young Neurosurgeons Liaison Departments

AANS National Office 2 President’s Message—AANS Takes the Lead in Defending 22 South Washington Street Against Pedicle Screw Litigation Park Ridge, Illinois 60068-4287 Telephone: (847) 692-9500 3 Washington Report—Proposed Changes in Practice Telefax: (847) 692-2589 E-mail: [email protected] Expense Reimbursement Threaten Neurosurgery Web site: http://www.neurosurgery.org Robert E. Draba, PhD, Executive Director 14 Managed Care Update Nancy S. Bashook, Dir. of Professional Development Laurie L. Behncke, CMP, Dir. of Meetings 22 Section News Robert T. Cowan, CPA, Controller Susan A. Nowicki, APR, Dir. of Communications 24 Professional Development David W. Reid, Dir. of Information Systems Steven L. Serfling, Dir. of Marketing & Membership Services 26 Research Foundation Tony Loster, CGCM, Production Manager 33 Membership Send change of address to: AANS 34 Positions 22 South Washington Street Park Ridge, Illinois 60068-4287 35 Announcements ©1997 by The American Association of Neurological Surgeons, all rights reserved. Contents may not be reproduced, stored in a retrieval system, or transmitted 36 In Memoriam in any form by any means without prior written permission of the publisher. 36 Calendar of Events

The AANS Bulletin is published quarterly by The American Association of Neurological Surgeons, 22 South Washington Street, Park Ridge, Illinois 60068-4287, (847) 692-9500, and is distributed without charge to the neurosurgical community. Unless specifically stated otherwise, the opinions Editor’s Note: expressed and statements made in this publication You may notice some changes in this issue of the AANS Bulletin. We’ve altered the reflect the authors’ personal observations and do design a bit to improve readability. We’ve added a new ongoing column on managed not imply endorsement by nor official policy of care. And, we’ve eliminated the mailing envelope to cut postage and handling costs. The American Association of Neurological More changes are due in coming issues and we hope they make the Bulletin a more Surgeons. valuable source of information for members. President’s message

Litigation Background also a wider range of defendants with AANS Takes the Lead in The AANS has long supported the similar interests. That has resulted in a Defending Against efficacy of pedicle screw fixation in close coordination of defense efforts and appropriate cases. That support remains the elimination of duplication of efforts by Pedicle Screw Litigation strong today. In 1993, we cooperated the law firms representing the associations. with the Food and Drug Administration Another important step we took to n many ways, (FDA) and several prominent medical ensure that the resources of the AANS were I the past year associations in conducting the retrospec- appropriately marshaled behind the defense has been one of tive Cohort Study. That study, involving was to appoint a blue-ribbon task force of ambiguity for the more than 300 surgeons and 3,000 prominent neurosurgeons, chaired by field of neurosur- patients, was the most comprehensive David Cahill, MD, to prepare an analysis of gery. Socioeco- study of the use of pedicle fixation ever the scientific and medical issues involved. nomic issues have conducted. While its methodology may That report has been completed, and, I created both not have been perfect, its conclusion that understand, has been extremely useful to controversy and pedicle screw systems are efficacious in our attorneys in responding to the issues opportunity for the reconstruction of certain types of raised in the litigation. neurosurgeons diseased and damaged spines was an like never before important contribution to the literature. Motion to Dismiss and research and Following the broadcast of the 20/20 Our attorneys, working in conjunction J. Charles Rich, Jr., MD development are television show that severely criticized (in with counsel for the other associations, bringing forth medical technologies and our view, unfairly) pedicle screws and the filed a comprehensive motion to dismiss treatments that were unimaginable even resulting explosion of litigation, Judge the “Omni” complaints last year. In 15 years ago. As President of the AANS, Louis Bechtle in Philadelphia was August, Judge Bechtle granted that motion I am frequently asked, “What is the designated as the multi-district judge to dismiss, but gave the plaintiffs leave to AANS doing for neurosurgeons to help who would coordinate all pedicle screw refile with amended complaints. Many them cope with the forces now threaten- cases filed in the federal courts. Because (although not all) chose to do so, which ing the future of neurosurgery?” the results of the FDA-sponsored led to renewed motions to dismiss filed by I can assure you that your professional Cohort Study so undermined the counsel for the associations. Those society has become a true leader and plaintiffs’ basic contention that pedicle motions were based on deficiencies of the advocate for the field of neurosurgery. screws are inherently dangerous and amended complaints in the allegations of Over the past year, the AANS has risen unsafe, the Plaintiffs’ Legal Committee the alleged conspiracy and in asserting to face some of our biggest challenges (PLC) attempted to attack that study some causation between the associations’ yet—the proposed changes in practice and its participants in an effort to activities and the injuries to each particular expense reimbursement by the Health discredit its results. plaintiff. In addition, First Amendment Care Finance Administration (HCFA), The AANS’s first involvement in that protections were asserted with respect to the pedicle screw litigation, and litigation was to take the lead in blocking anything taught or discussed at associa- increased competition from other Judge Bechtle’s imminent disclosure of tion-sponsored meetings. specialties—to name just a few. What the names of the participant surgeons The renewed motion to dismiss was the future holds for neurosurgery, we and perhaps their patients. That data had argued before Judge Bechtle on February cannot be sure, but through the work of been submitted by participating surgeons 7,1997, and he is expected to rule soon. such organizations like the AANS, we under an assurance of confidentiality by Counsel for the AANS is optimistic that can certainly try to manage influences the FDA. It was not until the interven- we will be dismissed from the litigation at over different facets and prepare for tion of the medical associations, led by some stage prior to remand of the cases whatever changes lie ahead. the AANS, that Judge Bechtle appreci- for trial, whether through this motion or Elsewhere in this issue of the Bulletin, ated the sensitivity of the confidentiality a subsequent one. you’ll be reading about our efforts in of those medical records. responding to the practice expense issue In due course, the AANS and many The Future for Pedicle Screws and the marketing communications other additional parties were drawn into You may have heard that one of the initiative we developed to increase the the litigation as defendants in complaints manufacturers, AcroMed, entered into a visibility of neurosurgeons in the public alleging a broad-ranging conspiracy to settlement agreement with the PLC. That arena. In this, my last President’s promote the products of the manufactur- settlement is being implemented by the Message, I wish to focus on the work ers. Our attorney was selected as the creation of a class of patients who received that the AANS has done in area of the liaison counsel for all of the medical AcroMed devices. The AANS and the pedicle screw litigation. associations in that litigation and has other medical associations were not parties taken the lead role in coordinating the to that agreement and had no voice in its efforts of not only those associations but (continued on page 13)

2 AANS Bulletin • Spring 1997 Proposed Changes in Practice Expense Reimbursement Threaten Neurosurgery Cover Story By Katie O. Orrico, JD Director AANS/CNS Washington Office

he Health Care Financing Adminis- reduction in total income if HCFA Overview of HCFA Practice Ttration (HCFA) is in the process of implements its current proposal on Expense Project and Implica- developing new relative value units for January 1, 1998, as now planned. tions for Neurosurgery the practice expense component of the This situation has galvanized much of Up until 1992, Medicare reimbursed resource based relative value scale organized medicine, prodding many physicians under the usual customary (RBRVS). The RBRVS is used by groups to initiate counter measures and reasonable (UCR) charge system. Medicare and many other private aimed at preventing the implementation There were many critics of this system insurers to determine reimbursement of this plan. Neurosurgery is at the and in the mid-1980’s, Congress levels. These changes threaten the long- forefront of this effort and has taken a decided to explore new ways to term viability of many specialty prac- very aggressive stance on the issue. The reimburse physicians. tices. Although a number of specialties goal of this article is to provide you with would face serious reductions in income background on the practice expense Legislative and Regulatory as a result of the proposed changes, controversy and to detail what your neurosurgery would be especially hard professional organizations are doing History of the RBRVS hit. In fact, neurosurgeons face a 25–35% about it. Based on Congressional mandates contained in the Consolidated Omnibus Reconciliation Act of 1985, the Omni- KEY PLAYERS IN THE RESOURCE-BASED bus Reconciliation Act of 1986, and the PRACTICE EXPENSES DEBATE Omnibus Reconciliation Act of 1987, HCFA began its efforts to develop a physician fee schedule based on a relative The key players in the resource-based practice expenses debate include all three branches of the federal government. value scale. The research was performed by a research team at Harvard University The Congress. The Congress initiated this project (when Democrats controlled both houses of School of Public Health, led by William Congress during President Clinton’s first term). There are three committees with primary Hsaio, PhD. The two main objectives jurisdiction over Medicare payment issues. The Finance Committee in the Senate and the Ways were to construct a system that was and Means and Commerce Committees in the House. Each committee has a health subcommit- more equitable (i.e., would increase tee. The Physician Payment Review Commission (PPRC) is a nonpartisan advisory body to the primary care and general internal Congress on matters related to health care. The PPRC initiated the research on resource-based medicine’s fees with a corresponding practice expenses and continues to be an influential player in this policy debate. decrease in the fees for surgeons and medical proceduralists) and would help The Executive. The agency with jurisdiction over this issue is the Department of Health and constrain Medicare physician expendi- Human Services (HHS). The Secretary of HHS has delegated the authority over matters such as tures. This was strongly supported by these to the Health Care Financing Administration (HCFA), the agency that administers the the American Society of Internal Medicare program. HCFA, in turn, has contracted with several researchers to collect the practice Medicine, with additional support by expense data. The primary contractor for this project is Abt Associates, a health research firm in the other primary care societies. Cambridge, Massachusetts. Once HCFA develops the new practice expense relative values it In 1989, Hsaio completed the initial must publish these in the Federal Register so the public has an opportunity for review and research, “A National Study of Resource comment. Prior to publication, the proposal must first be cleared by the Secretary of HHS and Based Relative Value Scale for Physician by the president, through the Office of Management and Budget (OMB). Services.” The Physician Payment The Judiciary. We may use the courts to challenge the accuracy and validity of the new Review Commission (PPRC), primary relative values or to challenge the process by which they are implemented. In general, the care organizations, and the AMA Medicare statute prohibits the courts from reviewing the substance of regulations promulgated by supported the concept (the American HCFA, but there may be a procedural challenge under the Administrative Practice Act. College of Surgeons opposed this effort). As a result, Congress enacted new Interest Organizations. Important non-governmental players include organized medicine— physician payment rules as part of the both physician and non-physician providers — and various health researchers. Additional groups Omnibus Reconciliation Act of 1989. that may become players include the academic health centers, nurses and the elderly. Through a series of rulemaking and refinement panels, HCFA transformed

AANS Bulletin • Spring 1997 3 Cover Story

the Hsaio research into relative values for sion factor to arrive at the fee for the perform a service. Currently, only the most CPT codes. The final fee schedule service. Currently there are three work component is “resource-based.” The became effective on January 1, 1992. different conversion factors: one for practice and malpractice expense surgical services, one for primary care components, on the other hand, are Components of the RBRVS services, and one for all other services. calculated from historical Medicare The RBRVS has three components— Thus, the payment formula is calcu- allowed charges and from data on work, practice expense, and malpractice lated as follows: practice expense and malpractice expense expense. Each component is multiplied revenue shares for different specialties. PAYMENT = CF x [RVU work x GPCI work) + by a geographic adjustment factor or Many argue that the current practice (RVU practice x GPCI practice) + GPCI (geographic practice cost index). expense methodology produces a bias in (RVU malpractice x GPCI malpractice)] The product of each component is then payments in favor of surgical and invasive procedures and against evaluation and added to one another to arrive at the Practice Expense Component management services. Since the inception total relative value for a given service. The work values of the RBRVS are of the RBRVS, numerous groups (includ- The total relative value units (RVUs) generally considered to be valid estimates ing the PPRC, AMA, primary care and are then multiplied by a dollar conver- of the physician resources required to general internal medicine organizations) have advocated that the practice expense Medicare vs. Medicaid vs. Medicare - 20% (Florida) $3,000 component should be resource-based. MEDICARE 1996 Since the inception of the RBRVS, $2,500 M EDICAID 1996 several pilot projects to develop resource- MEDICARE LESS 20%

$2,000 based practice expenses have been completed by researchers under the $1,500 sponsorship of HCFA, the PPRC, and

$1,000 other private organizations. In 1992, the PPRC issued a report outlining their $500 proposed methodology for calculating

$0 resource-based practice expenses. This methodology divided practice expenses 20926 20938 22554 22585 22612 22630 22842 22845 35301 61312 61313 61510 61700 63030 63035 63042 63047 63048 63075 63076 into direct and indirect costs for each service. Direct expenses are those costs Medicare vs. Medicaid vs. Medicare - 20% [Indiana] $2,500 attributed to a specific CPT code, e.g., MEDICARE 1996 clinical labor and equipment. Indirect MEDICAID 1996 $2,000 expenses are those costs common to all MEDICARE LESS 20% procedures, e.g., rent, telephone, some $1,500 labor. This approach assumes that those specialties that are hospital based, i.e., $1,000 surgery, have fewer practice expenses than those that are office based, i.e., primary $500

Figure 2 Figure 1 care. In its 1993 Annual Report to

$0 Congress, the PPRC formally recom- mended that Congress revise the practice 22554 22612 22842 22845 61107 61154 61510 61700 61751 61793 62223 63005 63030 63042 63047 63075 99213 99232 99243 99244 expense component to be resource-based. In 1993, Congress first responded with Medicare vs. Medicaid vs. Medicare - 20% [Iowa] $3,000 an interim approach in an effort to MEDICARE 1996 reduce some of the practice expense $2,500 MEDICAID 1996 RVUs for procedures that were deemed to MEDICARE LESS 20% $2,000 have excessive reimbursement for their practice costs. The Omnibus Reconcilia- $1,500 tion Act of 1993 included a provision

$1,000 that reduced the practice expense component to no greater than 128% of Figure 3 $500 the work RVUs (the initial proposal was 110%). Services performed in the office $0 more than 75% of the time were 22554 35301 61154 61312 61313 61510 61512 61700 61751 62223 62284 63017 63030 63042 63045 63047 63048 63075 exempted from this reduction. This had (continued on page 9)

4 AANS Bulletin • Spring 1997 Cover Story

(continued from page 4) collection process in February 1996 the recent adjustments made to the fee the greatest impact on the surgical (nearly one year after being awarded the schedule during the 5-year review of procedures (for neurosurgery, the spine contract). The first part of the data work RBRVS. The impact will be procedures took the biggest hit), many of collection process involved efforts to slightly larger, when HCFA includes which had practice expense relative values measure the non-physician time and those downward adjustments. They in excess of 140% of the work RVUs. labor that comprise the direct expenses of also do not reflect the proposal to adopt In October 1994, Congress passed the procedures. Abt. convened Clinical a single conversion factor for all Social Security Act Amendments. This law Practice Expert Panels (CPEPs), which providers, which would produce an directed the Secretary of Health and Human collected the direct cost data that could be additional 10% reduction in all Services to develop a resource-based system attributed to specific services and reimbursements for surgery. for determining practice expense RVUs. procedures. Follow-up CPEP II meetings Neurosurgeons are not the only In developing the methodology, the were held in June 1996 and were specialty adversely affected by HCFA’s Secretary was directed to consider the designed to extrapolate to the entire proposal. The hardest hit is Cardiac “staff, equipment, and supplies used in the group of CPT procedures from the initial Surgery, which faces total reductions from provision of various medical and surgical samples in CPEP I. 32% to 44%. Thoracic Surgery, Cardiol- services in various settings.” If Congress The second part of the data collection ogy, Vascular Surgery, and Gastroenterol- does not intervene, the new system will be process involved a national mail survey to ogy will face reductions ranging from 17% implemented on January 1, 1998. physicians. In April 1996, Abt sent Phase to 40%. General Surgery, Orthopedic I of the survey to 1,700 physician Surgery, and Plastic Surgery can expect HCFA Research practices. The purpose of the survey was reductions of 8% to 19%. The principal In November 1994, HCFA issued a to collect data on indirect costs and reason for the reductions is that HCFA’s request for proposals to develop data on service mix. In September 1996, because methodology assumes that when the practice expenses and case mix. In the of a poor response rate, HCFA canceled surgeon is in the hospital doing surgery, he spring of 1995, HCFA awarded the the mail survey. As a substitute, the or she is not incurring any overhead practice expense data collection contract agency decided to use the research of expenses—an obviously faulty assumption. to Abt Associates, Inc. The Abt approach Dunn and/or Pope to develop the Given that they have been the most was similar to that originally developed indirect expense component. In January vocal proponents of this new system, it is by the PPRC, wherein practice expenses 1997, HCFA released its preliminary ironic that under the current proposal are divided into two categories: direct and impact analysis. general Internal Medicine will at best indirect. These two “pots” are then added receive only a 4% increase. Family together to produce the total practice Impact on Neurosurgery Practice fares better with increases expense RVUs. The agency also funded two HCFA estimates that overall practice ranging from 9% to 19%. The big other projects to produce alternative expense changes will cut neurosurgery’s winners, however, are the non-physician methods of allocating indirect costs using total Medicare (and non-Medicare if providers (as was the case in the 5-year existing data and a formula-based approach. private insurance carriers adopt the fee review of work RVUs). Chiropractors will HCFA awarded these contracts to Daniel schedule as is) income by 25% to 35%, receive increases of 27% to 54%, Dunn and Eric Latimer of Harvard depending on the methodology Optometrists 35% to 40%, and Podia- University and Gregory Pope and Russell selected. (See Table 1 for some examples trists 23% to 41%. These specialties have Burge of Health Economics Research, Inc. of common neurosurgical procedures) significant increases because they perform After a series of meetings and prelimi- These figures are based on 1995 all of their services in an office setting. nary work, Abt began the actual data numbers and therefore do not reflect

CPT TOTAL 1997 1998 CODE DESCRIPTION RVU IMPACT MEDICARE FEE MEDICARE FEE

35301 Carotid endarterectomy -31% $1,361 $ 945 61107 Implant ventricular catheter -21% 462 365 61510 Remove brain tumor -39% 2,266 1,388 61700 Carotid aneurysm surgery -37% 2,957 1,876 62223 Establish brain shunt -34% 1,320 874 Table 1 Table 63030 Lumbar discectomy -33% 1,246 832 63047 Lumbar spinal decompress -38% 1,497 927 63075 Ant. Cervical discectomy -30% 1,661 1,162 * Note: These values represent base Medicare Fees without application of geographic adjustments, using the current surgical conversion factor.

AANS Bulletin • Spring 1997 9 Cover Story

Practice Expense Coalition

Medicare vs. Medicaid vs. Medicare - 30% [Kentucky] The Practice Expense Coalition (PEC) $3,000 first met in November of 1992 as a result Medicare 1996

$2,500 Medicaid 1996 of a PPRC conference on practice expenses Medicare less 30% (this first meeting arose out of the $2,000 discussions between AANS/CNS member

$1,500 Dr. Pevehouse and Dr. Rufus Stanley of the American Academy of Orthopedic $1,000 Surgeons). Initially, the coalition was led

Figure 4 $500 by the American College of Surgeons, but over time, the College relinquished its lead $0 role as more non-surgical organizations

22554 22585 22612 22630 22842 22845 61510 61512 61548 61700 63030 63042 63047 63048 63075 became interested in participating in a joint effort. Over the years, the coalition Medicare vs. Medicaid vs. Medicare - 20% (New York) has consisted of a loose confederation of $4,000

MEDICARE 1996 over 25 specialty organizations (including $3,500 MEDICAID 1996 all major surgical organizations and other $3,000 MEDICARE LESS 20% groups such as anesthesiology, pathology, $2,500 radiology, psychiatry, gastroenterology,

$2,000 cardiology, and dermatology). Its

$1,500 principal purpose has been to ensure that

$1,000 the new system provides a fair and accurate measure of physician practice Figure 5 $500 expenses. We have used the PEC as a $0 vehicle for keeping the federal policy 20660 22554 61070 61120 61210 61312 61510 61512 61548 61700 61790 61793 62223 63017 63020 63030 63042 63075 64721 makers focused on this premise. The PEC has been instrumental in Access to Neurosurgical Care for neurosurgical services provided to minimizing the negative effects of the practice expense reductions and will The AANS and CNS are very Medicaid patients. It is not likely that continue its efforts until all parties are concerned these cuts will have a signifi- Medicare rates will ever approach this low satisfied that the final HCFA product is cant impact on access to quality neuro- level. Nevertheless, the comparison methodologically sound and accurate. surgical care. Because of low Medicaid illustrates the potential access problems Over the past several years, the PEC reimbursement, many physicians are associated with significant reductions in has accomplished a number of things: reluctant to accept Medicaid recipients as Medicare reimbursement. patients. The same may be true for ■ In 1993, the PEC opposed President Medicare beneficiaries if reimbursement AANS/CNS Effort to Clinton’s budget proposal to limit levels reach a point where physicians are Ensure Accuracy practice expense RVUs to 110% of no longer able to maintain their practice work RVUs. The PEC successfully Organized surgery, including neuro- because they cannot meet their marginal lobbied Congress to raise the 110% surgery, has been an active participant in costs for the services provided. This figure to 128%. The PEC also the debate over resource-based practice problem is likely to be even more acute in implemented a strategy to defeat expenses. Again, the underlying theory the future given the fact that cost shifting legislation mandating resource-based is becoming ever more difficult with a of resource-based practice expenses is practice expenses, or at the least shrinking base of indemnity patients. that hospital-based specialties (primarily ensure that Congress did not spellout A survey of neurosurgical practices in surgeons) have fewer practice expenses in detail the specific methodology twenty states compared the relationship because they are not incurring overhead that HCFA must use in developing between Medicare and Medicaid fees expenses while working out of the office. new practice expense RVUs. Lan- given a 20% to 30% decrease in Medi- Since the beginning of this debate, the guage requiring resource-based care rates. In thirteen of these states, AANS and CNS have challenged this practice expenses was stripped from Medicare reimbursement for common fundamental premise. We have at- the final budget bill. neurosurgical procedures would reach or tempted to interface at every level to dip below current Medicaid rates. (See ensure that the final outcome represents ■ In 1994, the PEC had multiple Figures 1-10 for examples from 10 states.) a reliable, fair, and accurate product. meetings with Congressional staff to It is a mixed bag and highly dependent The following briefly outlines our refine the language that mandated the on the Medicaid payment levels. New interactions with the various players in adoption of resource-based practice York, for example, pays virtually nothing the practice expenses debate. expenses. These meetings resulted in 10 AANS Bulletin • Spring 1997 Cover Story

changes to the proposed language and the “sunshine.” The AANS and CNS will ■ In 1993, we objected to HCFA’s pushed the implementation date from continue to be very active participants in continued use of a site-of-service January 1997 to January 1998. the PEC as we fight the implementation payment differential, arguing that a of these arbitrary reductions. neurosurgeon’s practice expenses may ■ In 1996, at the PEC’s behest, Reps. actually increase when he/she Whitfield (R-KY) and Hall (D-TX) performs services in the hospital introduced a bill extending the Physician Payment Review setting. We reiterated our strong implementation date to January Commission opposition to the reduction of 1999. Unfortunately, the bill died The AANS and CNS have followed practice expense RVUs to 128% of when Congress adjourned last fall. the activities of the PPRC very closely the work RVU. Finally, we criticized since the Commission first began the approach the PPRC took in Since 1995, the PEC has also inter- significant work on practice expenses in developing preliminary resource- faced on an ongoing basis with HCFA 1992. Our principal means for commu- based practice expense for a small and other Clinton Administration nicating our ongoing concerns about this sample of procedures and recom- officials. These efforts have helped assure project has been in our testimony before mended that the Commission delay that this entire process is conducted in the Commission. making any final recommendations to Congress pending further study.

■ Medicare vs. Medicaid vs. Medicare - 30% (No.Carolina) In 1994, we reiterated our position that $3,000 MEDICARE 1996 any changes to the practice expense

$2,500 MEDICAID 1996 component of the RBRVS should fairly MEDICARE LESS 30% and accurately reflect the costs associ- $2,000 ated with the practicing neurosurgeon’s

$1,500 delivery of quality health care.

■ $1,000 In 1996, we recommended that the entire practice expense project be $500 revised so that the actual costs

$0 associated with the delivery of

22554 22614 22842 22845 35301 61107 61108 61210 61312 61510 61512 61518 61700 62223 62230 63020 63030 63042 63075 64721 neurosurgical services will be fairly and accurately reflected. We urged the Commission to recommend a one- Medicare vs. Medicaid vs. Medicare - 30% [Ohio] year delay and a three-year transition $2,500

MEDICARE 1996 period for new practice expense

$2,000 M EDICAID 1996 RVUs. We also provided the Com- MEDICARE LESS 30% mission with data showing that the $1,500 proposed cuts will reduce neurosur-

$1,000 geons’ Medicare fees below current Medicaid rates and noted the $500 potential access to care problems Figure 7 Figure 6 associated with such reductions. $0

20660 20931 22554 22845 61510 61700 61712 61720 61751 61793 61795 62140 62223 62230 62272 63030 63042 63047 63048 63075 Congress Much of the AANS and CNS interface

Medicare vs. Medicaid vs. Medicare - 30% [Oklahoma] with Congress has been in conjunction $3,000 with our participation in the Practice MEDICARE 1996 Expense Coalition and with the Ameri- $2,500 M EDICAID 1996 MEDICARE LESS 30% can College of Surgeons. We have had a $2,000 number of contacts with Congress,

$1,500 independent of the PEC and ACS.

$1,000 ■ In 1993, we activated our Key Person

$500 Network requesting that neurosur- Figure 8 geons contact members of Congress $0 urging them to reject the 110%

22554 22585 22612 22630 22842 22845 61510 61512 61548 61700 63030 63042 63047 63048 63075 proposal. Key Persons also wrote members of Congress expressing our

AANS Bulletin • Spring 1997 11 Cover Story

resulted in the AANS/CNS getting

Medicare vs. Medicaid vs. Medicare - 30% [So.Carolina] representation on the Orthopedic $3,000 CPEP. We wrote to Abt suggesting MEDICARE 1996 changes to the reference services $2,500 MEDICAID 1996

MEDICARE LESS 30% selected for review. Abt made some of $2,000 these changes. We nominated Drs.

$1,500 Florin and Lippe to the CPEP Technical Expert Group (TEG). Out $1,000 of many nominations from many

$500 specialty organizations, Dr. Florin was Figure 9 selected and helped develop the $0 process by which the CPEPs would

20660 20661 20926 22315 22595 22845 61070 61107 61154 61210 61312 61313 61510 61512 61700 62223 62230 62258 63015 63020 63030 63042 63047 63075 64721 operate. Finally, we nominated several neurosurgeons to participate on the Neurosurgery CPEP. Drs. Pelofsky, Medicare vs. Medicaid vs. Medicare - 30% [Texas]

$3,000 Travis, Roski, Cooper, Florin, and MEDICARE 1996 Kusske were selected to participate. MEDICAID 1996 $2,500 MEDICARE LESS 30% Two CPEP sessions were con- $2,000 ducted—February and June 1996.

$1,500 ■ In 1997, we submitted comments to

$1,000 HCFA in response to the preliminary practice expense data. We suggested $500 corrections to some of the data

Figure 10 $0 collected by the CPEPs and registered 22554 61154 61312 61313 61510 61512 61518 61548 61700 61793 63020 63030 63042 63045 63047 63081 63266 63281 64721 our ongoing complaints about the flawed nature of the project. concerns about legislation mandating through personal meetings, correspon- the development of resource-based dence, comments to proposed rule- American Medical Association practice expense RVUs. making, and through our participation in The AANS and CNS have interfaced the Practice Expense Coalition and with with the AMA at multiple levels. At ■ In 1996, several neurosurgeons met the American College of Surgeons. numerous meetings held in Washington, with Rep. Thomas (R-CA), Chair- DC, since the inception of the project, ■ man of the House Ways and Means In 1994, we met with HCFA staff staff have continued to raise our con- Health Subcommittee reiterating our regarding the agency’s plans for the cerns. In addition, Dr. Florin, through his view that, as currently configured, the development of resource-based practice participation on the AMA Relative Value concept of resource-based practice expenses and to determine the advisabil- Update Committee (RUC), has contin- expense is fundamentally flawed. The ity of the AANS/CNS undertaking our ued to voice our concerns. AANS and CNS issued a “Changing own practice expenses study. We were Most recently we actively sought Times” fax broadcast to all neurosur- advised that it was premature to conduct changes to official AMA policy through geons urging them to contact their our own study at that time. Nevertheless, the House of Delegates process. In June member of Congress in support of the based on a methodology developed by 1996 the AANS and CNS successfully Whitfield/Hall bill. Finally, at their Drs. Pelofsky and Roski (with indepen- led an effort to get the AMA House of request, AANS/CNS Washington dent validation by a Harvard account- Delegates to adopt a policy in support of staff met with House Commerce ing professor), we conducted an internal Committee staff and detailed the survey of a cross-section of neurosurgi- a one-year delay in implementation and status of the HCFA project and cal practices to ascertain the impact of legal action, if necessary. In December associated problems. practice expense. We then sent the results 1996 we participated in a successful effort of this study to HCFA for evaluation. to modify AMA policy, which now Health Care Financing requires the AMA to strongly advocate ■ In 1995, we submitted comments to that resource-based practice expense Administration and ABT Abt regarding the formation of the Associates Clinical Practice Expert Panels RVUs be based on actual physician The AANS and CNS have interfaced (CPEPs). We suggested that neurosur- practice expense data. In addition, the with HCFA on numerous occasions geons should be represented on AMA should only support new RVUs throughout the development of new several CPEPs other than that are methodologically sound and will practice expense RVUs. We have done so neurosurgery’s own CPEP. This not have a negative effect on the ability of 12 AANS Bulletin • Spring 1997 Cover Story

physicians to provide high-quality tation of the current practice expense ■ Seek relief from the Office of medical services. project and we are prepared to challenge Management and Budget this proposal at every level of govern- ■ American College of Surgeons ment. It is clear that the effort to redesign Seek legislative relief from Congress As stated above, since the inception of the system has failed and most organiza- ■ Develop an alternative legislative/ this project, the AANS and CNS have tions agree that regardless of whether you regulatory proposal for calculating worked closely on a number of levels with are a “winner” or “loser” there are serious practice expenses the College. The College has also been questions as to the validity of the data, ■ very active over the past years on all and the current January 1, 1998, Review avenues for potential litigation implementation date needs to change. fronts—Congress, PPRC, HCFA, etc. ■ Develop and implement a compre- The implications of the HCFA practice Like the AANS and CNS, throughout the hensive grassroots action plan process the College has continued to expense estimates are profound and reach strongly object to the direction HCFA is far beyond the immediate impact on ■ Develop and implement a compre- taking on this project. We are currently physicians’ incomes. Congress therefore hensive AANS/CNS membership involved with a College study of surgeons’ needs to direct HCFA to move down communications plan another path. No amount of refinement, practice expenses. This study is being By the time this issue of the Bulletin is transition, or delay will solve the conducted by Lewin-VHI, Inc., a health published, we will be well on our way to problems with this study. research firm, and will hopefully produce a implementing our campaign. The issue will If the AANS and CNS are to be favorable alternative to HCFA’s proposal. likely be addressed by the Congress in successful, specialty medicine must speak conjunction with the debate over the Gathering Data with one voice and strike one deal. budget and Medicare reform. If Congress The AANS and CNS recently commis- Congress will not likely listen to surgery stays on schedule, we may have some sioned The Gary Siegel Organization to alone, so it is important to build as broad resolution by October 1, 1997. (See Table collect practice expense data from several a coalition as possible. Primary care and 2 for HCFA’s Implementation Schedule) neurosurgical practices. The purpose of general internal medicine (and possibly The AANS and CNS leadership will this project is to provide independently the non-physician providers such as the continue to keep our members informed collected data to validate the data gener- chiropractors) will be lobbying against us about this issue as we move forward to ated by the Abt and Lewin projects. and in favor of the current proposal. They defeat this unacceptable proposal. We If favorable, we will likely use the are a formidable force and in the past won’t be able to do it alone, however. We results to influence changes to the HCFA have been successful at painting this as a will need each and every neurosurgeon to data when the proposed rule is issued in surgery only issue. The leadership be involved in this campaign! May. We may also need to use these data recognizes this and has agreed to work For more information, please contact in conjunction with our efforts to show closely with non-surgical organizations Katie Orrico in the Washington Office at Congress (and possibly the courts) that through our participation in the Practice (202) 628-2072. the HCFA project contains inaccurate Expense Coalition. President’s Message data that does not reflect the actual The AANS and CNS have committed continued from page 2 significant resources to the PEC effort. practice expenses of neurosurgeons. terms. We are, however, indirect beneficia- At press time our strategy has not been ries in that all litigation against the finalized, but we will be considering the Future Activities to associations based on AcroMed devices will following activities: Prevent Implementation be dismissed with prejudice. The AANS and CNS will be aggressive ■ Conduct a technical evaluation of the We believe that it is both unfortunate in their efforts to prevent the implemen- HCFA proposal and inappropriate for medical associa- tions, such as the AANS, to be forced to HCFA’s Timetable for Implementation defend this type of litigation. We will continue to defend not only the integrity of the AANS, but also the efficacy of April 1, 1997 Begin Internal Clearance Process pedicle screw fixation systems in appro- May 1, 1997 Publish Proposed Rule in Federal Register priate cases and the rights of our July 1, 1997 60-Day Public Comment Period Ends members to use those systems where, in August 1997 Conduct Data Refinement Panels their judgment, it is in the best interests September 1997 Draft Final Rule of their respective patients.

Table 2 Table October 1997 Begin Internal Clearance Process Sincerely, November 1, 1997 Publish Final Rule in the Federal Register January 1, 1998 New Practice Expense RVUs Go Into Effect J. Charles Rich, MD President AANS Bulletin • Spring 1997 13 MANAGED CARE update has been overwhelmingly transformed in million during 1995. Neurosurgeons saw Managed Care Process less than a decade. Investor capital is now big jumps in revenues from HMOs over creating the first truly national physician the last two years. Across all specialties, Now Well Entrenched enterprises, fashioning medical practice according to 1996 data from Medical By John A. Kusske, MD on a scale wholly unknown in the past. Economics, doctors have gotten the The first reports suggest, according to message. The percentage of Midwestern anaged care has been defined by Governance Committee data, that Wall physicians participating in HMOs and MEdward F.X. Hughes, MD, MPH, Street driven enterprises are setting new PPOs now exceeds that of their western professor of Health Services Management standards of competition in every market colleagues and eastern and southern at Northwestern University, as “the sector in which they compete and are doctors aren’t far behind. process of the application of standard outperforming industry norms by every Medical Economics reports that 83 business practices to the delivery of health conceivable measure. Competing to the percent of neurosurgeons surveyed care in the traditions of the American free new standard must be within the reach of participate in HMOs and 81 percent in enterprise system.” As Hughes points out, local, nonprofit systems of physicians and PPOs. Interestingly, their data shows that managed care is a process and not a hospitals if they are to survive. The neurosurgeons’ median gross income collection of things. Rather, it is change success of investor-owned enterprises is from HMOs reached $115,860 in 1995. itself. This change is inexorable. principally a story of discipline and The surveyed neurosurgeons also Managed care is a uniquely American resolve, not scale or Wall Street capital. reported that 30 percent of their active invention, and like many other American patients were HMO enrollees and 10 inventions, Hughes believes it will HMO Enrollment Soars percent were PPO members. It was also ultimately grow to dominate the world The most recent numbers from clear from the study that practice size because there really is no alternative to InterStudy, an HMO research group correlated with managed care participa- managed care to rationalize the cost and based in Minneapolis, reveal that HMO tion, with the percentage of HMO/PPO quality of care. In his view the sine qua enrollment soared 15 percent, to 58.4 (continued on page 16) non, the process of managed care is the presence of management in the health field as it has never before existed. HMOs’ Insidious Intrusion Management, according to Hughes, is empowered to make decisions regarding The following letter to the editor appeared in the February 28, 1997, issue of the Wall the appropriate mix of production factors Street Journal. It was written by Harvey F. Wachsman, MD, neurosurgeon and attorney, to achieve the desired health outcomes of in response to a front-page feature story in that publication which described how HMOs a defined population for which the are asking nurses, in a cost-cutting move, to assume some duties previously performed by management is now accountable. The physicians. His point is that HMOs are finding new ways to cut costs at the patient’s expense. essence of managed care is management’s “Nurses taking over the duties of doctors (Nurses to Take Doctor Duties, Oxford choosing from a mix of possible inputs Says,” Feb. 7) is the latest example of a health care provider being squeezed by a to achieve the highest quality of care for profit-minded HMO into a position where it must reduce the quality of patient care the defined population at the least in order to save money. That this practice is taking place at Columbia Presbyterian possible cost. Medical Center is particularly disturbing, because it shows that not even one of the nation’s most prestigious institutions is immune from the HMOs’ economic pressure. Era of Corporate Medicine “Advocates say that nurses will spend more time with patients than doctors do. But it was the HMOs that interfered with physicians’ practices and forced them to Now Dawning spend less time with patients in the first place. They say that patients will be able to U.S. health care ended the twentieth choose between seeing a doctor or a nurse. But with Columbia Presbyterian leading century as it began, still primarily a cottage the way, it can’t be long before this becomes such a common practice that patients industry, according to a recent Governance have no real choice at all. Committee publication. Physician practices “First, HMOs restricted doctors’ ability to practice as they saw fit, limiting their and hospitals remain largely unorganized, ability to order tests, admit patients to the hospital, and refer patients to specialists. principally charitable or private endeav- Apparently, these companies, whose executives are reaping lofty salaries in the face of ors. However, the new era of corporate huge profits, are not content with merely controlling the way physicians practice medicine is dawning and the enormous medicine. They are now trying to take patient care out of their hands completely opportunity in health care is only now and turn it over to nurses, who lack the training and expertise doctors possess. beginning to catch Wall Street’s eye. “As a neurosurgeon and attorney, I have already seen numerous cases of people As the Governance Committee report whose lives have been destroyed because of ill-advised HMO policies. Everyone who reveals, the migration of HMOs from is concerned about the future of health care in America—doctors, lawyers, patients, potential patients—should draw the line in the sand and let our public officials local, nonprofit corporations to national know that we need new laws to protect the public and our healthcare system against scale and public ownership is already the insidious intrusion of HMOs.” nearly complete—the payer community

14 AANS Bulletin • Spring 1997 AANS and CNS Launch a New Joint Communications Program Focusing on the Nature and Benefits of Neurosurgery By Stan Pelofsky, MD Ad Hoc Committee on Communications

eurosurgery faces significant program should educate as well as see a neurosurgeon if they have symptoms Nchallenges to the professional status inform. Finally, and most importantly, we of lumbar stenosis. and livelihood of its members and the felt strong member involvement was specialty. Buffeted as we are by the needed in order to ensure its success. Recruiting Volunteers to Lead growing shifts in reimbursement patterns In summary, the overall goals of the the Way and encroachments by other specialties program are to: To be effective, the program must be into our traditional scope of practice, the ■ linked to the hundreds of practices that Joint Council of State Neurological Increase awareness of the scope and quality of neurosurgery. make up our specialty. This will not be Societies (JCSNS) planted the seed last easy. Neurosurgeons are busy. Some of year for a national effort by neurosur- ■ Engage members in a program of you may feel ill-equipped or uncomfort- geons to come forward and be heard. It is public and professional education able about promoting neurosurgery and vital that we speak up and remind about the specialty. its services. But we are asking members of consumers, referring physicians, third- the AANS and CNS to “raise your hands” ■ Promote the timely, appropriate party payers, and even the media about to volunteer as local-market Ambassadors application of neurosurgical solutions the value and contributions of neurosur- for the program. to health needs. gical care to the well being of patients. Each volunteer will be asked to identify In this context, The American ■ Help neurosurgery enhance and (with the help of prepared media listings) Association of Neurological Surgeons expand its role as a valued provider of the local media outlets to whom informa- (AANS), Congress of Neurological health care. tion kits should be sent in his/her name. Surgeons (CNS), and the JCSNS created Any neurosurgeon may voluntarily The topic we chose for the first phase an Ad Hoc Committee on Communica- become an Ambassador for this special of our Getting SMART program is tions to consider and recommend a initiative. Each Ambassador will receive a lumbar spinal stenosis (LSS). Once our communications program that could kit containing program materials and communications process has proven its address the challenges of today’s guides to using them. Materials will effectiveness, the Committee, with input healthcare marketplace. This Committee include the following: consisted of myself, Edward R. Laws, Jr., from our Sections, will develop other MD, Bruce Kaufman, MD, Mitchel topics to be given similar support. ■ A backgrounder and Q&A on lumbar Berger, MD, Susan Nowicki, APR, stenosis and treatment options. AANS Director of Communications, and Guiding Position ■ Press releases and guides to working David Tabolt, an outside communica- In broad terms, the position guiding with local print and electronic media. tions consultant based in Chicago. development of the LSS communications initiative is that tens of thousands of older ■ Patient and referring-physician Program Elements Americans are suffering severe, unneces- brochures that can be customized to We determined that such a program sary pain and are being forced to give up their practices. active lives prematurely because an would be most effective if it was designed ■ Educational slide presentation and increasingly common affliction—lumbar to build awareness of the specialty of teaching syllabus on lumbar stenosis. neurosurgery incrementally, over time, spinal stenosis—is not diagnosed and rather than all at once on a grand scale. treated soon enough with successful ■ Sample letters to media, referring This is in keeping with guiding philoso- neurosurgery. practitioners, and hospital CME phy of the AANS Long-Range Plan that Neurosurgery can restore most of these directors. activities should be specific, measurable, patients to vital, active lives in a matter of attainable, relevant, and time-framed weeks or months, but, unfortunately, The aim is not to make our volunteers (SMART). The CNS concurs with these managed care and the lack of information public relations experts, rather it is to defined activities as well. on the part of patients and the general equip them with the tools necessary to The Committee decided that each public are keeping a growing number of tell our story in a comprehensive and phase of the program should place patients from being referred to neurosur- coordinated way. emphasis on a common condition where geons for spinal problems. Primary neurosurgery should be the provider of doctors must be made aware of this Media Outreach choice, but currently does not enjoy an disease and when it is appropriate to refer In addition to the Ambassadors’ efforts, exclusive position. We also felt the patients. Further, patients should ask to the National Office will coordinate a AANS Bulletin • Spring 1997 15 program to alert national and special- to HMO and other managed care Then we will distribute our materials to interest publications about the issue of decision makers. We believe that making participants and begin our media outreach. LSS and neurosurgery. Target audiences these gatekeepers aware that neurosur- I hope that all of you will consider will include national news publications, geons provide spinal surgery services and joining the program as an Ambassador. If as well as other general, senior citizen, are the leading providers of LSS services you cannot do so, I hope that you will women’s, health, and healthy living will be beneficial. utilize the physician referral materials in magazines and newsletters, and national your community. and syndicated broadcasting and editorial Joining the Program More than at any time in our history, outlets and heath care trade publications. Members who wish to take full advantage it is important that we educate our The program will be supplemented by of this public education and professional patients, colleagues, and policy—makers a special edition of Neurosurgical Focus in outreach communications program as about the valued role that neurosurgeons August 1997. Ambassadors will receive 200 copies of play in the health care continuum. And the patient LSS brochure, 100 copies of who better to teach that lesson than you. Incorporate Messages That the referring practitioner brochure, slide Advance Neurosurgery presentation, personalized press kits mailed to BECOME AN AMBASSADOR All materials and key media messages up to five local media outlets, and training. focus on both the specific patient benefits If you volunteer to be an Ambassador, FOR NEUROSURGERY! of the services offered and why neurosur- you will be asked to commit to making at gery is the “provider of choice.” Ambassa- least two public/professional presentations, If you would like to enroll as an dors are encouraged to represent the mailing referral source brochures to at least Ambassador for the Lumbar Spinal specialty as a whole, and to advocate 50 persons, and to cooperate with media Stenosis Communications Program, neurosurgery’s capabilities. interviews. You will also be asked to please contact the Communications Ambassadors will be asked to forward contribute $195 to support the program. Department at the AANS National news clips and their success stories to the At the same time, all active AANS and Office for an enrollment form. Call National Office, who will prepare regular CNS members who are not Ambassadors (847)692-9500 and direct your reports to notify members of the will be eligible to separately purchase sets inquiry to Susan Nowicki, APR, program’s progress and to provide of 100 patient brochures and 50 referral Director of Communications. If you Ambassadors with tips and ideas for source brochures for $100. Reorder sets are interested only in ordering sets of making the program more effective. of public-only brochures will be available patient and/or physician referral for $50 per hundred. materials, contact Laura Weiss in the Referral Program We will be conducting a volunteer Order Services Department for an A separate package of materials is being recruitment effort for the next 60 days to order form. developed for referring physicians. These establish our network of Ambassadors. materials can be used as leave-behinds at Managed Care Update presentations and in mailings to primary Continued from page 14 care providers and other referral sources. contracts higher in groups of four or Future Trends The package will include: more physicians. Increasing managed care penetration 1. Referral guidelines Like hospitals, specialists are on the followed by capitation, or other compen- 2. Background on LSS endangered species list wherever managed sation plans, deselection and ultimately 3. Frequently asked questions care makes inroads, according to recent declining physician incomes is a cycle 4. Copies of patient and professional comments in Integrated Healthcare Report that will continue to play out as long as brochures (IHR). Only a small percentage of neurosurgical services are undifferentiated 5. Sample letters to referral sources existing specialists in these markets are and there is a surplus of neurosurgeons. Program Ambassadors will be encour- needed to serve the members. HMOs When the dust settles after the year 2000, aged to disseminate the LSS background and primary care contracting groups put there may be fewer neurosurgeons left information as broadly as possible. these specialists under intense scrutiny. If standing, but those who are will be those Copies of the referral materials also will their utilization and cost profiles are too who recognize the opportunities and start be available for purchase by members high, they may be deselected. But the to reposition themselves today. who choose not to participate in the good performers, according to IHR, are In future columns, we will look at broader Ambassador program. increasingly being singled out and recent trends, changes, tips, and different grouped up for specialty network ways managed care influences neurosurgi- Gatekeeper Advocacy participation. Those who aren’t included cal practice including cost containment, In addition to its outreach to referral in these networks are bypassed and lose group contracting, physician-hospital sources, it is the intent of this program to patients. Too often, neurosurgeons in organizations, and capitation. develop a case for neurosurgery as the these markets are blindsided because they “practitioner of choice” for presentation don’t plan for the future. 16 AANS Bulletin • Spring 1997 N://OCspring 1997

What Is Neurosurgery? Web sites. A free copy of OpCoder is also NEUROSURGERY:// ■ Definition of Neurosurgery available for downloading. Developed by ■ Glossary of Terms Joel MacDonald, MD, an N://OC® ON-CALL™ ■ History of Neurosurgery Editorial Board member, OpCoder is ■ About the AANS and CNS designed to accurately catalog operative Continues to Expand procedure details and can produce custom Services Patient Resources reports, including RRC forms and brief ■ Informational pieces on neurosurgical operative notes for the medical record. disorders ■ How to find support groups for Outcomes NEUROSURGERY://ON-CALL™ neurological disorders The Outcomes and Guidelines continues to grow and improve, provid- ■ Graphics on the anatomy of the brain Committee of the Joint Section on ing useful resources for our members. and spine Cerebrovascular Surgery has developed Over the past few months, the Editorial ■ “Ask A Neurosurgeon”—a question Outcomes Reporting Instruments for Board and staff have been hard at work and answer feature that gives patients carotid artery surgery and intracranial developing new features for the Web site. the chance to query a neurosurgeon aneurysm surgery. These instruments are If you haven’t already, be sure to visit about a predesignated topic via e-mail formatted in a Java based program ® N://OC at www.neurosurgery.org to ■ “Find A Neurosurgeon”—a directory available on N://OC®. check out the following: of AANS and CNS members The instruments will be able to be searchable by name, city/province, downloaded to individual computers to Real Audio Slide Presentations and area code. Members may choose allow neurosurgeons to keep local databases. N://OC® takes advantage of streaming to upgrade their free directory listing In addition, the data can be submitted to audio by utilizing Real Audio technology. to provide more details about the Web site where a combined database The first three online slide show presenta- themselves and their practice (contact will be kept. The program automatically tions we offer focus on: THINK FIRST, Allison Casey at the National Office strips patient identifiers from the data Brain Attack, and Carotid Endarterec- for more information). submitted, thus insuring patient confi- tomy. In order to view these slide shows, Physician Resources dentiality. As reporting instruments for you will need to have the Real Audio ■ Referral guidelines other neurosurgical problems are player installed on your computer. A free ■ Learning modules developed, they can be formatted for use copy is available on the Real Audio Web with this Java-based program. site, and we provide a direct link to their Neurosurgery News ■ site from N://OC®. Media kits ■ New “Look” We plan to post selected AANS Annual Positions statements ■ Press releases for Navigation Meeting presentations as Real Audio slide In order to shows, and will gradually build a library improve access to of talks from the AANS and CNS Amazon.com You can now order neurosurgical pages within the meetings that can be viewed anytime, at site, we have your convenience. related books through Amazon.com, the Internet’s largest online bookstore. As implemented a part of the Associates Program, N://OC® new navigation bar Public Pages offers a convenient way to browse for (see illustration). We are pleased to introduce a new books online. In the Marketplace section While the Thinker section dedicated to providing valuable of the site, you will find listings of books image remains a neurosurgical information to patients, organized by subspecialty. To order, just central figure to ® referring physicians, and the overall click on the book title and you will be N://OC , you can health care community. We encourage taken directly to the ordering page of the now utilize small you to visit this part of the site also, Amazon.com site. menu item images because it contains material that you to navigate within might find helpful in providing to your the site. Resident Corner patients. The information can be printed directly off the site and given to your A brand new section of the site, Online patients, or you can encourage them to Resident Corner, focuses on providing resources to current and future neurosur- Abstract access the site themselves. The Public Submission Pages section offers the following gical residents. In this section, you will Abstracts for the information: find a complete listing of accredited residency programs throughout the 1997 CNS Annual United States, including links to their (continued on page 36)

AANS Bulletin • Spring 1997 21 Section news

by the Division of Neurosurgery from number of centers, which will log all cases Joint Section on Pediatric Allegheny University of the Health with acute cervical cord injury admitted Neurological Surgery Sciences, began with presentations on to their centers and then entering as many Examines CPT Codes for “Spine and Nerve Injuries in Athletes” by eligible patients as possible into the early Cranial Endoscopic Surgery several neurosurgeons, including Mark decompression protocol. McMaster By Harold Rekate, MD Hadley, MD, Dr. Day, Charles Tator, University is the Statistical Coordinating Chairman MD, Dave Kline, MD, Jack Wilberger, Center and the University of Toronto is the MD, and Richard Douglas, MD. Clinical Coordinating Center for this trial. The development of specific CPT codes An in-depth symposium followed on The study officially got underway on for cranial endoscopic surgery has been the “Neuropsychological Assessment of October 1, 1996, with participating an on-going topic for discussion among Athletes” and the last session covered the neurosurgeons in 14 centers. members of the AANS/CNS Joint important area of “Concussion in Section on Pediatric Neurological Athletes,” and included concussion Surgery. A 1996 survey of a selected classification and concussion guidelines Investigator Location with papers delivered by Joseph Maroon, group of surgeons who perform a Edward Benzel, MD Albuquerque, NM substantial volume of cranial endoscopic MD, Robert Cantu, MD, Tom Gennarelli, MD, and Ralph Dacey, MD. Brian Cuddy, MD Charleston, SC procedures demonstrated variation in Donald Cooney, MD Washington, DC billing practices using existing, nonspe- There was an important panel discussion on the Professional Athletes Perspective Michael Fehlings, MD Toronto, ONT cific CPT codes. The respondents and Mahmood Fazl, MD indicated that payers generally were with National Football League players including Lynn Swann, Harry Carson, Richard Fessler, MD Gainesville, FL reimbursing them for their work. Barth Green, MD Miami, FL Because of the risk that development of Merril Hoge, and Mike Tomczak. The Sports Medicine Committee is Patrick Hitchon, MD Iowa City, IA new CPT codes for endoscopy might Dennis Maiman, MD Milwaukee, WI actually lead to lower reimbursement, the performing the important function of interfacing with the sports medicine Larry Marshall, MD San Diego, CA Executive Council of the Joint Section on Bruce Northrup, MD Philadelphia, PA Pediatric Neurological Surgery decided at community at large, which includes not only injured athletes, but also professional Steven Papadopoulos, MD Ann Arbor, MI its 1996 Annual Meeting in Charleston Volker Sonntag, MD Phoenix, AR to take no further steps toward approval and amateur leagues, athletic trainers, and other medical and non-medical organiza- Frank Wagner, MD Sacramento, CA of new codes. Payers’ reimbursement Jack Wilberger, MD Pittsburgh, PA practices are, however, in a state of tions and specialists involved in the continual evolution, and the Executive treatment of athletes, and the prevention Council wishes to continue to monitor of athletic injuries. All of these groups These centers were chosen on the basis the experiences of the membership. and individuals benefit from the strong of their experience in conducting clinical Members are encouraged to contact input from individual neurosurgeons and trials in spinal cord injury in NASCIS-3 Joseph Piatt, MD, at (503) 494-8070, fax from organized neurosurgery. This is an or the GM-1 trials. (503) 494-7161, e-mail [email protected], area in which neurosurgeons and The Pilot Study aims to determine to report denials of payment or other neurosurgery perform a real public whether decompression can be diagnosed difficulties. service. Congratulations to Dr. Bailes for by MRI or CT myelography and then waving the neurosurgical flag high with treated by traction alone, surgery alone, Joint Section on Neurotrauma this course. or both within the 8-hour trauma-to- and Critical Care Co-Sponsors treatment time window. This timing is Trauma Section and Joint Section Successful Course on Sports the only confirmed trauma-to-treatment on Spine Launch Pilot Study of interval in the spinal cord injury field and Related Concussion and Nervous Early Decompression of Acute was established by the NASCIS-2 trial System Injuries Cervical Cord Injury in 14 Centers with methylprednisolone. Patients must By Charles H. Tator, MD, PhD By Charles H. Tator, MD, PhD have cervical cord compression fully Chairman Principal Investigator documented prior to treatment and then must have decompression accomplished Julian Bailes, MD, Chair of the Joint The Joint Section on Neurotrauma and by 8 hours after trauma. Section’s Committee on Sports Medicine, the Joint Section on Surgery of the Spine was the Course Director along with Mark and Peripheral Nerves are co-sponsoring a When moving remember to Lovell, a Neuropsychology Consultant to pilot study organized by the National send your change of address to: the National Football League, and Arthur Institutes of Health (NIH) to determine Day, MD, the former Sports Medicine AANS Member Services the feasibility of a larger randomized Committee Chair, for this excellent 200- 22 South Washington Street control trial of early decompression. The registrant course. The meeting, organized Park Ridge, Illinois 60068-4287 study will be performed in a small 22 AANS Bulletin • Spring 1997 ACS Board of Regents Holds

Winter Meeting provided a template that covers the AMA Update general areas of medical consequences of There was significant discussion intervention, patient perception and regarding the American Medical Associa- satisfaction, quality of life, and cost. tion (AMA) meeting and the presence of he American The Advisory Councils view these surgeons within the AMA structure. The College of Surgeons T studies as important because they provide surgical caucus under the leadership of (ACS) Board of Regents long-term functional assessment and will the American College of Surgeons seems met February 7–8, 1997 provide for managed care entities and the to be a more effective voice, however, it is in Phoenix, Arizona, government, evidence of quality medical recognized that the AMA continues to be and covered a good deal care, improvement in the individual organized along political lines, and of the of business. surgeon’s position in the competitive 447 members of the House of Delegates, marketplace, and some means of achieving only 175 are surgeons. A move to enlarge Education cost control. Neurosurgery is moving the Board of Directors to include some The study on ahead with projects related to cerebrovas- more surgeons was not approved. Edward R. Laws, Jr., MD, FACS prerequisite objectives cular disease, spinal surgery, and brain The recent balloting conducted by the Regent for Neurosurgery for graduate surgical American College of Surgeons tumors under this general scheme. AMA to expand federation representation education is nearly resulted in the College of Surgeons complete and is an excellent survey of the Practice Guidelines and Liability improving its position so it now has two desirable aspects of medical school The report of the Professional Liability delegates and two alternates; we will go curriculum needed for individuals going Committee raised a number of concerns ahead and appoint these additional into surgery or the surgical subspecialties. to whether practice guidelines were in members. Overall, surgeons gained nine Neurosurgery has made significant fact a major problem in the liability seats and non-surgeons gained 12. The contributions to this effort and the results arena. Because of these concerns, the American Society of General Surgery also of the study will be circulated as soon as Agency for Health Care Policy and has a seat. Unfortunately, neurosurgeons they are available. Research (AHCPR) has halted its did not gain additional representation as It was noted that the most recent development of guidelines. not enough votes were received from our longitudinal study of surgical residents In the tort reform arena, a study came neurosurgical colleagues. covering the year 1993 to 1994 contains forth that suggested that $25 to $50 billion It should be noted that the AMA erroneous data with regard to graduates of in excess costs could be saved if there were House of Delegates did go on record at its neurosurgical residencies. It suggests that appropriate liability reform. The College June meeting to support a delay for there was a 40 percent increase, but this continues to worry about the traveling implementation of the practice expense has occurred simply because they started expert witness problem and has referred readjustments and also supported our with the year 1983 as a baseline, and this physicians at the College to IDEX. At least initiative for relief in matters of GME, was the year before significant expansion 12 doctors successfully defended lawsuits and there is some optimism with regard in both number and length of training with information provided by this agency. to the ability for surgery to work with the programs occurred in neurosurgery. If a new leadership in the AMA. baseline of 1985 had been chosen, there Resource-Based Practice Expense would be no change. This underscores the Legislation Trials and Grants danger in some of the manpower and The major factors for discussion under The ACS has applied to National workforce determinations done by others. physician reimbursement were the fee Cancer Institute for a clinical trials grant The College has supported schedule updates, the MVPS, and, of that would cover a number of areas of neurosurgery’s initiative to obtain course, the practice expense issue. It was surgery. The request is for $31 million antitrust relief so that graduate medical noted that resource-based practice over five years, and the initial studies education issues could be addressed on expenses represent about 42 percent of would cover lung, breast and colon the basis of quality of training programs each surgical fee code. We were already cancer, along with melanoma and with perhaps some changes in reducing scheduled to lose about 13 percent on the retinoblastoma. A neurosurgical group the number of residents trained. change in the conversion factor, and the has been formed and will be available for various subspecialties stand to lose a good trials if this grant is approved. Task Force on Outcomes deal more if the resource-based practice The Committee on Emerging Surgical The Advisory Councils for the surgical expense adjustments become law. Technology has applied to the National subspecialities have been quite active, It was felt that a delay in implementa- Institutes of Health and the Veteran’s with neurosurgery being one of the tion is almost certain, but our position is Administration for a prospective trial of leaders. They have moved forward with one of not supporting a delay, but rather laproscopic versus open management of the Task Force on Outcomes Research pushing for repeal and making sure that inguinal hernia. and the current report has been approved the conversion factor changes are by the Board of Regents. The College has somehow acceptable. AANS Bulletin • Spring 1997 23 Professional development NEW COURSES!

NEUROSURGERY REVIEW BY CASE MANAGEMENT: ORAL BOARD PREPARATION May 3–5, San Diego, California November 9–11, Houston, Texas Chairman: Julius M. Goodman, MD

If you are a neurosurgeon in private, academic, or subspecialty practice who is contem- plating taking oral boards in May 1997, or within the next several years, this intense three-day course is for you! Experienced faculty will use the oral board format to cover a broad review of neurosurgery. There will be opportunity to become updated on mate- rial infrequently encountered in your practice and to get actual experience answering questions under pressure.

EXTRACRANIAL CAROTID RECONSTRUCTION May 30–31, Rancho Mirage, California Chairman: Christopher M. Loftus, MD, FACS Associate Chairman: Issam A. Awad, MD

Don’t miss this innovative program! There is a didactic portion of the course that fea- tures a strong emphasis on management issues and clinical decision making. Plus, a unique feature of this course is the opportunity to participate in a day-long, hands-on live animal laboratory. The lab time allows you to refine skills in carotid exposure, ateriotomy technique with primary and/or patch graft repair, shunt insertion, and both loupe-magnified and microsurgical techniques. There is a special session devoted to placement of carotid interposition grafts.

SURGICAL MANAGEMENT OF MOVEMENT DISORDERS June 27–29, Orlando, Florida Co-Chairmen: William T. Couldwell, MD, PhD & Robert G. Grossman, MD

Don’t miss this advanced course! Surgical treatment of Parkinson’s Disease and other The American Association of Neurological Surgeons movement disorders is regaining popularity. If you want to revisit this treatment, you should take this course. Faculty with experience in these surgical treatments will review For more information or to the current indications and techniques used to treat patients with Parkinson’s Disease and other movement disorders. In interactive discussions, participants and faculty will register for these courses, call examine current controversies in surgical technique. the Professional Development Department at (847)692-9500.

24 AANS Bulletin • Spring 1997 SURGERY OF THE CERVICAL SPINE–HANDS-ON NEUROSURGICAL CRITICAL June 27–29, Memphis, Tennessee CARE FOR NEUROSURGEONS, NEUROSCIENCE NURSES & Chairmen: Regis W. Haid, MD & Iain H. Kalfas, MD PHYSICIAN ASSISTANTS June 5–7, Philadelphia, Pennsylvania Mark Your Calendar Now for This Exceptional Opportunity! Chairman: Michael J. Rosner, MD

If you want to expand your expertise in cervical spine surgery, this course Significantly increase your ability to offers a comprehensive review of current concepts for the neurosurgical manage critically ill patients! This practitioner. course is uniquely suited for neuro- surgeons and their clinical associates Based on intensive interactive discussions, laboratory sessions will focus on and is specially designed to optimize human cadaver hands-on surgical instruction. You will see and perform a your learning experience. The course variety of decompression and stabilization techniques, including fixation emphasizes the team approach to techniques, utilizing screws, wires, and plates–all under the direction of scientific management of critically recognized neurosurgical experts. There also will be discussion and the ill patients by applying quantitative opportunity for hands-on practice with spinal stereotactic systems. relationships associated with neuro- surgical diseases. You will be provided You are strongly encouraged to bring your challenging patient cases to the with the most up-to-date information course for discussion. available on cerebral perfusion pressure management, modern fluid management, and cerebral pathophysiology.

A PROACTIVE APPROACH TO MANAGED CARE: STRATEGIES & SOLUTIONS June 21–22, Cleveland, Ohio November 7–8, Palm Beach, Florida

Chairman: John A. Kusske, MD REMINDER!! This course is a must-attend for neurosurgeons and their administrators! Do you know how to tell the difference between an essential and a wasted effort in approaching managed care? This course is designed to sharpen your per- The Professional Development ceptions, challenge your thinking, and motivate you to act decisively and Program exists to offer neurosur- proactively. Building on the foundation of previous managed care courses, geons the opportunities for con- this year’s program offers less historic background on managed care and more tinuing medical education. insights into what’s really happening. However, some courses continue to grow in attendance, and we must turn away registrations. Please help us to serve you by registering early so that you can attend the courses you want.

AANS Bulletin • Spring 1997 25 Research foundation AANS Research he Executive Council of the AANS to expand scientific knowledge. They AANS Research T Research Foundation gratefully deserve the highest recognition. acknowledges the following individuals, This list represents gifts of $100 or Foundation Recognizes groups, and corporations for their more received between January 1, 1996, generous contributions to the and February 15, 1997. The number 1996 Annual Foundation’s 1996 Campaign. These appearing in parentheses following each Campaign Donors donors have set exemplary standards for individual’s name indicates the number of the entire neuroscientific community by years he or she has supported the demonstrating the power of philanthropy Research Foundation Annual Campaign.

CUSHING SCHOLARS CIRCLE SUMMA CUM LAUDE MAGNA CUM LAUDE (Gifts of $5,000 and up) (Gifts of $2,500–$4,999) Dr. and Mrs. Merwyn S. Bagan (10) Mrs. Ruby C. Keller (14) Lester A. Mount, MD (3) Robert L. Martuza, MD (9) (in memory of Ruth A. Mount) Dr. & Mrs. Russell H. Patterson, Jr. (15) Bruce D. San Filippo, MD (3)

CUM LAUDE (Gifts of $1,000–$2,499)

Michael L.J. Apuzzo, MD (3) Robert L. Grubb, Jr., MD (8) Howard W. Morgan, Jr., MD (1) Dr. & Mrs. Arthur O. Schilp (2) Walter L. Bailey, MD (10) Barton L. Guthrie, MD (3) Dr. & Mrs. William J. Nelson (1) (in memory of Dr. Fremont C. Timir Banerjee, MD (12) Mark N. Hadley, MD (2) W. Jerry Oakes, MD (2) Peck) Lawrence F. Borges, MD (9) Griffith Harsh IV, MD (5) Dr. & Mrs. Herbert M. Oestreich (6) Dr. & Mrs. John F. Schuhmacher (11) Dr. Derek A. & Frances Bruce (6) Gregory A. Helm, MD (1) Christopher S. Ogilvy, MD (1) Edward L. Seljeskog, MD (10) Paul H. Chapman, MD (12) Julian T. Hoff, MD (5) Robert G. Ojemann, MD (12) Chun-jen Shih, MD (4) Hans C. Coester, MD (4) John A. Jane, MD. PhD (7) Christopher Paramore, MD (1) Ladislau Steiner, MD, PhD (6) G. Rees Cosgrove, MD (6) Neal F. Kassell, MD (6) Tae Sung Park, MD (2) Dr. & Mrs. Oscar Sugar (15) Fernando G. Diaz, MD, PhD (6) Patrick J. Kelly, MD (2) A. John Popp, MD (10) Brooke Swearingen, MD (1) Richard A. Dirrenberger, MD (5) Dr. & Mrs. Robert B. King (15) Robert Raskind, MD* Dr. & Mrs. Russell L. Travis (5) Winfield S. Fisher III, MD (3) Edward R. Laws, Jr., MD (8) (in memory from Mrs. Darline Martin H. Weiss, MD (3) Allan L. Gardner, MD (9) Timothy B. Mapstone, MD (8) B. Raskind) Dr. H. Richard & Deborah Winn (5) Steven L. Giannotta, MD (3) James M. Markert, MD (1) J. Charles Rich, Jr., MD (4) Shokei Yamada, MD (7) (a tribute G. Yancey Gillespie, PhD (1) Dr. & Mrs. Philip J. Marra (2) Michael J. Rosner, MD (2) to Shotetsu Yamada, MD) Julius M. Goodman, MD (11) Dr. & Mrs. Daniel L. McKinney (3) Dr. & Mrs. C. David Scheibert (2) Nicholas T. Zervas, MD (12) Paul A. Grabb, MD (1) Richard B. Morawetz, MD (4) (in memory of David W. Scheibert) * Deceased

Honor Roll Members (Gifts of $500–$999)

Drs. Ronald I. Apfelbaum & Walter A. Hall, MD (3) Robert L. Macdonald, MD (3) Anthony A. Salerni, MD (3) Kathleen A. Murray (4) L. Nelson Hopkins III, MD (8) Robert E. Maxwell, MD, PhD (4) Warren R. Selman, MD (10) Drs. Aaron J. & Doreen Berman (6) Reuben Hoppenstein, MD, FACS (4) Jay More, MD (1) Dennis L. Shubert, MD, PhD (1) Albert J. Camma, MD (8) (in memory of Emanuel Raj K. Narayan, MD (1) Dr. & Mrs. C. David Sundstrom (3) Robert M. Crowell, MD (8) Feiring, MD, FACS & Leo M. Walter R. Neill, MD (1) James C. Tibbetts, MD (9) Stewart B. Dunsker, MD (7) Davidoff, MD, FACS) Michael J. O’Connor, MD (2) (in memory of George Gregg N. Dyste, MD (1) Samuel S. Kasoff, MD (4) Dr. & Mrs. Vivekanand Palavali (1) Stepanian, MD) Donald L. Erickson, MD (4) David L. Kelly, Jr., MD (9) Dr. & Mrs. Savvas Papazoglou (3) Dr. & Mrs. Sidney Tolchin (6) Stephen R. Freidberg, MD (11) Louis L. Kralick, MD (6) (a tribute to Peter Schurr, Hani J. Tuffaha, MD (4) William F. Ganz, MD (3) Michael H. Lavyne, MD (5) CBE, MA, MB, FRCS) Jack E. Wilberger, MD (4) Sidney Goldring, MD (9) (a tribute to Drs. Nicholas Dr. & Mrs. Robert A. Ratcheson (13) Fremont P. Wirth, MD (12) Robert G. Grossman, MD (12) Zervas & Robert G. Ojemann) Setti S. Rengachary, MD (9) Stephen J. Haines, MD (5) 26 AANS Bulletin • Spring 1997 Research foundation continued

Foundation Sponsors (Gifts of $250–$499)

Eben Alexander III, MD (9) Dr. & Mrs. Robert A. Feldman (6) Joseph R. Madsen, MD (3) Michael Schulder, MD (4) Adele Auchmoody * Dr. & Mrs. Henry Feuer (10) Dr. & Mrs. Paul B. Nelson (5) R. Michael Scott, MD (4) (in memory from her family Liliana C. Goumnerova, MD (3) Carlos M. Ongkiko, Jr., MD (8) Dr. & Mrs. Scott A. Shapiro (5) and friends) Dr. & Mrs. Michael D. Heafner, Andrew D. Parent, MD (10) Julius A. Silvidi, MD (3) Dr. Richard E. & Marilynn J. Sr. (2) William L. Pritchard, MD (3) Dr. & Mrs. Carson J. Thompson (1) Balch (9) Jerry L. Hubbard, MD (4) Dr. & Mrs. Donald O. Quest (3) Larry D. Tice, MD (9) Vallo Benjamin, MD (10) (in memory of Thoralf Sundt, Dr. & Mrs. Harold L. Rekate (4) Suzie C. Tindall, MD (5) Peter McL. Black, MD, PhD (5) Jr., MD) Mr. Steven L. Serfling (3) James M. Vascik, MD (1) Dr. & Mrs. Jeff W. Chen (1) T. A. Kingman, MD (6) Dr. & Mrs. Edward B. Edgar N. Weaver, Jr., MD (4) Mauricio Collada, Jr., MD (1) Laurence I. Kleiner, MD (1) Schlesinger (1) Dr. & Mrs. Young Jae Yu (12) David Danoff, MD (10) David G. Kline, MD (4) (in memory of Ruth A. (a tribute to Robert B. King, MD) Drs. Tom & Leslie Doolittle (3) Dr. & Mrs. Mark J. Kubala (6) Mount) Max E. Zarling, MD (3) Robert E. Draba, PhD (1) Foundation Supporters (Gifts of $100–$249)

Adnan A. Abla, MD (3) Mel H. Epstein, MD (6) David I. Levy, MD (1) Michael H. Robbins, MD (3) Robert E. Albright, Jr., MD (1) John Feibel, MD (4) Dr. & Mrs. N. Scott Litofsky (2) Jack P. Rock, MD (2) Rick Anderson, MD (3) Thomas B. Freeman, MD (5) Sean R. Logan, MD (3) William S. Rosenberg, MD (2) Arthur G. Arand, MD (1) Phillip Friedman, MD (6) Lucy Carole Love, MD (5) Mark L. Rosenblum, MD (5) Wilson T. Asfora, MD (1) Gerhard M. Friehs, MD (2) Asim Mahmood, MD (3) H.L. Rosomoff, MD (4) Reza P. Asli, MD (4) David M. Frim, MD (1) Ghaus Malik, MD (3) Gail L. Rosseau, MD (1) John L.D. Atkinson, MD (4) (a tribute to Robert G. Dr. & Mrs. James B. Mansfield (12) Paul Sanberg, MD (2) Behnam Badie, MD (1) Ojemann, MD) Joseph C. Maroon, MD (10) Stephen C. Saris, MD (5) Julian E. Bailes, Jr., MD (4) Takanori Fukushima, MD (3) Bruce M. McCormack, MD (2) Thomas G. Saul, MD (5) Nicholas M. Barbaro, MD (4) Edward O. Gammel, MD (6) Michael W. McDermott, MD (3) Robert E. Schultz, Sr., MD (12) Dr. & Mrs. James E. Barnes (2) Yogesh Gandhi, MD (1) Thomas J. McDonald, MD (2) Donald M. Seyfried, MD (2) Jerry Bauer, MD (1) Vicente C. Gracias, MD (8) Frank M. Moore, MD (3) Yucel Sezgin, MD (5) (a tribute to Mr. Jeffrey Samuel H. Greenblatt, MD (5) Dr. & Mrs. Richard P. Moser (3) Charles P. Shank, MD (3) Wolfson) A. Lee Greiner, MD (5) Bradley G. Mullen, MD (3) Bradbury A. Skidmore, MD (1) Dr. & Mrs. Carl H.H. Baumann (2) Marshall L. Grode, MD (3) Swami Nathan, MD (5) Stephen L. Skirboll, MD (1) (in memory of Paul C. Bucy, Mary Kay Gumerlock, MD (3) Molly W. Nemann, EdD (1) Donald R. Smith, MD (4) MD) J. Frederick Harrington, Jr., MD (2) Russell P. Nockels, MD (3) Frank P. Smith, MD (2) David W. Beck, MD (1) Dr. & Mrs. Robert D. Harris (6) Georg C. Noren, MD (3) Kenneth R. Smith, Jr., MD (6) Thomas S. Berger, MD (5) (in memory of Robert Clubb, Thomas E. O’Hara, Jr., MD (4) Mark A. Spatola, MD (5) Mitchel S. Berger, MD (4) MD) Clark J. Okulski, DO (4) A. A. Steinberger, MD (4) Russell L. Blaylock, MD (1) Dan S. Heffez, MD (1) Richard A. Olafson, MD (6) Mr. William J. Sullivan (1) Ricardo H. Brau, MD (9) M. Peter Heilbrun, MD (11) Dr. & Mrs. Jeffrey Olson (3) (in memory of Ruth A. Steven Brem, MD (3) Fredric A. Helmer, MD (2) Frank T. Padberg, MD (2) Mount) Lewis J. Brown, MD (6) David A. Herz, MD (12) (in memory of Dr. Loyal Jamal M. Taha, MD (1) Richard B. Budde, MD (5) Mary Louise Hlavin, MD (4) Davis) John M. Tew, Jr., MD (7) David W. Cahill, MD (6) Victor T. Ho, MD (1) Luis F. Pagani, MD (4) William D. Tobler, MD (5) Arnold B. Calica, MD (4) Dr. Jonathan & Janet Hodes (3) Dr. & Mrs. Joseph C. Parker, Jr. (1) Stephen A. Torrey, MD (7) Candace K. Carlton, MD (1) P. Shripathi Holla, MD (3) (in memory of Alice Horsley Gregory R. Trost, MD (1) Dr. & Mrs. Shelley N. Chou (8) Kathryn L. Holloway, MD (1) Parker) Robert G. Tureen, PhD (1) William F. Collins, Jr., MD (10) James P. Hollowell, MD (3) Dr. & Mrs. Dwight Parkinson (12) Harry R. vanLoveren, MD (5) Kerry R. Crone, MD (5) Manucher J. Javid, MD (4) Dr. & Mrs. Sunil J. Patel (1) Wayne G. Villanueva, MD (6) Robert J. Dempsey, MD (2) Fredrick Junn, MD (1) Wayne S. Paullus, Jr., MD (2) Beverly C. Walters, MD (4) Bret A. Dirks, MD (1) Paul M. Kanev, MD (2) Ms. Chris Ann Philips (5) Ronald E. Warnick, MD (4) Curtis E. Doberstein, MD (2) Dr. & Mrs. Ellis B. Keener (12) Lawrence H. Pitts, MD (10) Philip R. Weinstein, MD (10) Richard A. Douglas, MD (4) Christopher Kircher, MD (1) Dr. & Mrs. Morris W. Pulliam (2) Dr. & Mrs. William L. White (9) Jose G. Duarte, MD (3) Dr. & Mrs. Douglas R. Koontz (1) Matthew R. Quigley, MD (4) Jack E. Wilberger, MD (4) John A. Duncan III, MD (3) Dr. & Mrs. Edward J. Kosnik (6) Lincoln F. Ramirez, MD (2) Stuart R. Winston, MD (13) Stewart B. Dunsker, MD (7) Barry A. Kriegsfeld, MD (4) Joseph Ransohoff, MD (6) Hwa-shain Yeh, MD (6) Fredric L. Edelman, MD (6) Willliam B. Kuhn, MD (3) Justin W. Renaudin, MD (4) Mario Zuccarello, MD (2) Kost Elisevich, MD, PhD (3) Arnold C. Lang, MD (4) Howard Anthony Richter, MD (11) * Deceased AANS Bulletin • Spring 1997 27 Research foundation continued

Scientific Society

The following list consists of university programs, foundations, groups, and organizations that have contributed $500 or more within the last year. Individual members of these groups are listed within the giving category that corresponds to their individual portion of the total gift.

Boston Neurosurgical Foundation, Boston, MA Louisiana Neurosurgical Society Brown University Neurosurgical Foundation, Providence, RI Massachusetts General Hospital, Boston, MA Cleveland Clinic Foundation, Cleveland, OH Mayfield Clinic, Cincinnati, OH Dartmouth-Hitchcock Medical Center - Neurosurgery, North Carolina Neurosurgical Society Lebanon, NH Tri-State Neurosurgical Associates, Pittsburgh, PA Henry Ford Hospital, Detroit, MI University of Alabama at Birmingham Georgetown University, Washington, DC University of California, San Francisco Georgia Neurosurgical Society, Atlanta, GA University of Minnesota Jewish Communal Fund, New York, NY University of South Florida Joint Section of Cerebrovascular Surgery University of Southern California Keller Foundation, Dix Hills, NY University of Wisconsin

The Executive Council of the Research Foundation GIVE MORE BY asks that you join with them in GIVING EARLY! applauding the efforts of the following companies: Giving your Research Foundation 1997 Annual Sustaining Associates Campaign gift early in the (Gifts of $50,000–$75,000) year adds value to your gift. Synthes Spine/Synthes Maxillofacial Divisions HOW? Supporting Associates Your gift is “put to work,” earning (Gifts of $25,000–$50,000) interest, almost immediately! Your Codman/Johnson & Johnson Professional, Inc. Elekta donation, which goes in its entirety Leibinger to the endowment fund, begins to Sofamor Danek earn interest early in the year, thereby increasing the dollars available for the next funding cycle Associates of grants and awards. (Gifts of $5,000–$10,000) Aesculap Help to ensure a bright future DePuy Motech neuroscientific research. Send your Corporate Associates Roster Midas Rex Institute 1997 gift today. For your conve- Pharmacia & Upjohn, Inc. nience, a Research Foundation gift ® PMT Corporation envelope has been inserted in this copy of the AANS Bulletin.

28 AANS Bulletin • Spring 1997 Membershipspring 1997

Acknowledging this, the AANS formed ship has nearly tripled since 1994. Today, AANS Membership the Young Neurosurgeons Committee in 121 nurses and 46 physician assistants are 1992. At the same time, the eligibility members of the AANS. Exceeds 5,000 requirement of the Candidate category of In order for the AANS to truly be the membership was expanded from neurosurgical voice of North America, neurosurgical residents in their last two the eligibility requirements of the Active he AANS has experienced tremen- years of residency to all neurosurgical category of membership have been T dous membership growth over the residents in ACGME and RCS approved broadened. Last year, Bylaw changes past few years. Recently, the total number training programs. With only 61 opened the category to neurosurgeons of AANS members exceeded 5,000, Candidate members in 1993, the total certified by the Mexican Council of extending its position as the largest number of Candidate members today Neurological Surgery, A.C. Therefore, neurosurgical organization in North exceeds 550, giving the AANS more we expect to see a significant increase in America. More than 1,000 new members resident members than any other the number of Active members in the have joined the AANS during the past neurosurgical society. years to come. three years, doubling the number of To elaborate on the importance of a The AANS strives to provide its applications being reviewed by the collaborative approach to medicine, the members with a forum for the exchange Membership Committees. AANS opened its arms to certified of issues, ideas, problems, solutions, and neuroscience nurses and physician developments in the field of neurosur- Just Who Are These New assistants in 1994. The eligibility gery while creating an opportunity to Members? requirements of the Associate category of build professional relationships. The The AANS recognizes that optimal membership were modified to include AANS is on the leading edge of neuro- patient care is comprised of a collabora- nurses with CCRN (critical care), surgery and is working harder than ever tive approach to medical treatment. Our CNRN (neuroscience), or CNOR to remain in this position. The AANS future neurosurgical leaders need (operating room) certification, and wants you to be proud of your role in educational guidance from experienced certified physician assistants (PA-C). As a North America’s largest society of neurosurgeons, and yet, their own voice. result, the Associate category of member- neurosurgical professionals.

M. Samy Abdou James R. Hirsh Karl D. Schultz, Jr. Ayman Fahad Al-Shayji Philip Joseph Hlavac David Howard Shafron Clark Hunter Allen Laura Horky Reza Shahim Arun Paul Amar William Scott Huneycutt Abdalla R. Shamisa Marc Shaun Arginteanu Mark R. Iantosca Nathan Eric Simmons Florence Carsley Barnett George Frazier Jackson III Jodi Linn Smith Lynn Margaret Bartl Robert John Jackson Robert Jay Spinner Jonathan Jay Baskin Michael Guenther Kaiser Kevin L. Stevenson Curtis Lee Beauregard George John Kaptain Robert D. Strang Steven Joseph Beer Jordi Xirinachs Kellogg Christopher Taylor Ronald Patrick Benitez Joseph L. Koen Albert Edward Telfeian Rajesh K. Bindal Todd Michael Lasner Robert Eugene Tibbs, Jr. Alan Samuel Boulos Daniel M. Lieberman Christopher R. Tomaras Kimberly Sue Brown Jae Yun Lim Neil A. Troffkin James Paul Burke Ted Tai-Sen Lin Sagun Kaur Tuli Jennifer Chambers Kernan William Gunter Loudon Ceslovas Vaicys Steven D. Chang Amir Malik Kevin A. Vaught Veronica Lok Sea Chiang Lloyd Ian Maliner Dominic Venne Frank Jeffrey Coufal Taras Masnik Federico C. Vinas Michael James Drewek Douglas C. Mathews John B. Wahlig, Jr. Derek Addison Duke Alon Y. Mogilner Wayne Lee Warren, Jr. Susan Renee Durham Praveen V. Mummaneni Joseph Clark Watson Deborah R. Elyaderan Ilyas Munshi Jeffrey Steven Weinberg Seyed Mohammad Emadian Bernardo J. Ordonez David Matthew Weitman Andrew D. Firlik Renatta J. Osterdock Timothy Mitchell Wiebe Katrina Schreiber Firlik Ian F. Parney Dennis Damian Winters Thomas Robert Forget, Jr. Bryan Rankin Payne Neill M. Wright Mark Benjamin Gerber Matthew Frank Philips Kennedy Yalamanchili Holly S. Gilmer-Hill Joseph Keith Preston Joseph S. Yazdi Ryan Scott Glasser Patrick Robinson Pritchard Peter Jinnbin Yeh Candidate Members for Spring 1997 James David Guest Robert Edward Replogle Julie E. York James Shields Harrod Howard Anthony Riina Ofer M. Zikel David Houston Harter Robert Dugald Robinson Gregory J. Zipfel Ian M. Heger

AANS Bulletin • Spring 1997 33 Positions spring 1997

Although the AANS believes these classified advertisements to be from reputable sources, the Association does not investigate offers and assumes no liability concerning them. 34 AANS Bulletin • Spring 1997 Announcementsspring 1997

Names in the News dedication to duty and devotion to University College of Medicine. Dr. soldiers during the past 28 years Dennis has been active in the Society for Michael E. Carey, MD, Professor of exemplifies the highest traditions of several years and also serves on the Neurosurgery at Louisiana State Medical military service and reflects distinct credit Board of Trustees for the National Center, has been awarded the seventh upon him and the United States Army.” Medical Association, on the Medical highest U.S. Army decoration, the A combat neurosurgeon, Dr. Carey Advisory Board of the Mid Atlantic Legion of Merit. served as Chief of Neurosurgery of the Heath Care Purchasing Coalition, and is The certificate accompanying the 312-91st Evacuation Hospital in Chu a member of the Practicing Physicians Legion of Merit reads, “Colonel Carey’s Lai, South Vietnam, as well as Chief of Advisory Council for the Heath Care professionalism, exceptional neurosur- Neurosurgery of the 148th Evacuation Financing Administration. gery skills, and keen insight were Hospital in Al Quasimah, Saudi Arabia, instrumental in the world renowned during Desert Storm. Phillipp M. Lippe, MD, FACS, research on head wounds including FACPM, was presented the Byron Cone follow-up studies on Vietnam veterans, Gary C. Dennis, MD, FACS, was Pevehouse Distinguished Service Award his approach to soldiers’ care, dynamic recently elected President of the Medical at the Annual Meeting of the California training abilities, and sense of patriotism Society of the District of Columbia Association of Neurological Surgeons. have been eminently visible throughout (MSDS). Dr. Dennis is the Chief of the Dr. Lippe is a Clinical Professor of his military career. Colonel Carey’s Division of Neurosurgery at Howard Neurological Surgery at Stanford and Chairman of the Department of Clinical Calendar of Neurosurgical Events Neurosciences at Good Samaritan Hospital in San Jose. 1997 Annual Meeting of the Congress of Neurological Surgeons September 27–October 2 Nicholas T. Zervas, MD, was elected a New Orleans, Louisiana Fellow of the American Academy of Arts New Orleans Convention Center and Sciences. Contact: Annual Meeting Services Department Dr. Zervas is Chief of Neurological (847)692-9500 Service at Massachusetts General in Boston. 1997 Annual Meeting of the North American Spine Society October 22–26 N://OC® New York Hilton Hotel & Towers continued from page 21 New York City, New York Meeting can now be submitted online. Contact: Patricia Fuller To access the abstract form, click on the (847)698-1630 Online Abstract Center link on the Hot Topics Page. The online abstract form Associate mirrors the text version. Derek C. Harwood-Nash, MD October, 1996 ABNS ® Lifetime N://OC is pleased to be hosting the Charles W. Berklund, MD John T. Lord, MD new Web site of the American Board of November, 1996 October, 1996 Neurological Surgery, which is located at Robert J. Clubb, MD Hector N. MacKinnon, MD http://www.abns.org. October, 1996 December, 1996 Feedback Encouraged Nicholas Gotten, Sr., MD Wylie McKissock, MD October, 1996 1993 NEUROSURGERY://ON-CALL™ welcomes your comments and sugges- Marshall Henry, MD Howard E. Medinets, MD tions. As the public pages section January, 1997 1996 continues to grow, content suggestions, Richard T. Johnson, MD Jorge A. Picaza, MD link ideas, etc., are appreciated. In Memoriam In Memoriam In Memoriam In Memoriam In Memoriam September, 1996 1997 To contact the Editorial Board with Fredrick Latimer, MD Pierre Wertheimer, MD your suggestions, send them e-mail at October 19, 1996 1982 [email protected] or write them at: Jean Lecuire, MD W. Lewis Yarborough, MD AANS National Office, 1992 July, 1996 22 South Washington Street, Park Ridge, Illinois 60068-4287. 36 AANS Bulletin • Spring 1997