Flotte’s Outlines

Neurosurgery: Economics & Politics

General Medical Economics

American Association of Neurological Surgeons

· Founded 1938.

· Harvey Cushing Society, founded 1932

· Neurosurgical Society of America, founded 1948

Congress of Neurological Surgeons

· Founded in 1950 for younger neurosurgeons, excluded from the older societies

· Limits its leadership to 45 years or younger

· “Fifty Years of the CNS”, Barrow DL N8/00

Society of Neurological Surgeons

· Established in 1920

ER Coverage

· See “Emergency Room Coverage, What Every Neurosurgeon Should Know” by the AANS/CNS Joint Section on Neurotrauma and Critical Care

· One in five neurosurgeons in the US now receives stipends ranging from $500 to $1,500 per night for providing emergency room coverage at trauma centers.

· Neurosurgeons are expected to take call as a condition of medical staff membership.

· EMTALA regulations dictate that specialty availability on a hospital call schedule must extend to the hospital Emergency Department (ED), obligating medical staff to trauma call.

· 57% of all high-acuity trauma patients have some neurologic injury, and half of the 150,000 injury-related deaths that occur annually in the United States involve a serious brain injury that is primarily responsible for the patient’s demise

· Neurotrauma contracts:

o Transfer agreements are ideally worked out in the context of a state or regional trauma system and should include predefined criteria to avoid EMTALA violations.

o Specifically dangerous to the institution is any implication that a neurosurgeon who contracts for trauma coverage is compelled to bring elective work to the hospital. Major regulatory concerns have arisen over these antikickback “payment for referral” issues, and hospital systems have been made to pay considerable fines and have undergone substantial federal scrutiny for such schemes.

o Estimating fair market value is critical. The best yardstick may be local or regional data as long as demographics, average Injury Severity Scores, and the like are comparable. These figures are difficult to come by, and large regional and demographic variability is likely to exist. National figures will reflect reimbursement methodology for similar institutions more broadly, but such data compilations are likewise not widely available. The Council of State Neurosurgical Societies (CSNS) has recently completed a national Internet survey on key socioeconomic parameters of emergency neurosurgery and neurotrauma.

o Neurosurgeons and their hospitals have developed a variety of creative arrangements for making trauma coverage both fiscally and physically responsible. Smaller community hospitals with a limited number of neurosurgeons have worked out cross-coverage arrangements, periodic locum tenens, or temporary transfer agreements to shield their neurosurgeons from the burden of excessive call requirements. Hospitals may bill patients directly and reimburse a guaranteed percentage of the neurosurgeon’s trauma receivables or simply provide billing services for the neurosurgeon. Hospitals may supply oncampus office space to allow for ready neurosurgical availability. Since neurotrauma coverage is widely perceived as increasing exposure to medicolegal liability, some institutions have agreed to pay for additional malpractice coverage and, in some cases, cover the entire amount. "Neurotrauma Director" positions may be created for neurosurgeons most involved in program development, along with a negotiated annual consulting fee.

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Revised: 2/9/07

Text Copyright 2007