Response to economic forces buffeting the community of neurosurgery.

Eighty-nine years ago, neurosurgery emerged as a new specialty, recognized by the American College of Surgeons in October 1919. By 1920, Harvey Cushing and 10 others formed the Society of Neurological Surgeons, today’s Senior Society. Since then, neurosurgery has expanded exponentially, with technical devices, surgical procedures, and practice standards undreamed of by these founders. Every new neurosurgeon finishing this rigorous and demanding training renews our specialty’s commitment to altruistic service, excellence in performance, and advancement of the knowledge and technical capability of our specialty. We face a new challenge, however, testing whether our specialty, or even medicine as a whole, can remain true to its guiding principles and purposes. We are confronted by economic forces that threaten neurosurgical research, training, practices, technical advances, and the welfare of all who benefit from the service that only neurosurgery can provide. We are victims, in a sense, of our own success. Health care costs have increased at 8% to 10% per year for 45 years, and there is no sign of slowing. We provide services in a competitive commercial market, which serves a public need, but it a creates a demand for neurosurgical and other types of care that drives the cost of health care upward at a rate at least twice as fast as the growth of our national economic resources to pay for it. Economic projections show that it is an unsustainable rate of growth.3 We are blamed, at least in part, for contributing to a growing family health insurance premium that exceeds onefourth of an average family’s income. We are blamed for adding to the burden of health benefits of employers who pay for them for their workers, a cost that eats away at their profits and cuts away at their workers’ wage increases. The number of employers providing health benefits has decreased from 69% to 60% over the past 8 years. Despite genuine technical advances, we are blamed for costs because of wide regional variations in care, such as lumbar fusions, variations that are said to imply either inconsistent indications or unnecessary treatments, both of which add cost without benefit.5 We are blamed for inconsistent quality and complications or errors that double the cost of a hospitalization. We are blamed for lacking the scientific evidence to justify many, if not most, of our decisions for treatment. The blame is pervasive, and it is generally because of money. We are also troubled by commercialism. We are accused of instances of conflicts of interest with the medical device industry, to get something for nothing and, in exchange, to use their products, either unnecessarily or preferentially, driving up costs. Because of costs, we are offered pay-for-performance bonuses for reporting processes of care, which for surgery are often selected simply because they can be measured, not because they have anything to do with the need, the quality, or the outcome of treatment. Congressional overrides of scheduled Medicare fee cuts create an annual political circus. We are threatened with Medicare fee cuts by a Sustainable Growth Rate formula that, if enforced, would slash Medicare fees 40% over the next 7 years, by 20% in 2010 alone. This has become a kind of chess game in Congress every year, with physicians as pawns, and what we get are fee cuts disguised as increases, and, in exchange, we are saddled with ever more regulation over practice each year. Medicare payment policy reverberates throughout the commercial health sector. Private payers shadow Medicare’s falling fees like a hollow echo. Beyond that, the Justice Department subjects physicians to billing audits, with threats of federal fraud and criminal prosecution, all to save money in federal health care programs. Some neurosurgeons pay outrageous premiums for medical liability insurance, but we are told that the cost has not gone up exorbitantly and that defensive medicine does not really affect costs of care, even while common sense says that it does. The Congressional Budget Office, the Medicare Trustees, the Government Accountability Office, and the Medicare Payment Advisory Commission all advise that Medicare’s current rate of growth, if unchecked, will bankrupt the federal Copyright © 2009 by The Congress of Neurological Surgeons 0148-703/09/5600-0070