- Email: [email protected]
North American Spine Society 2000 Presidential Address
The Spine Journal 1 (2001) 5–7
North American Spine Society 2000 Presidential Address Neil Kahanovitz, MD* I would truly like to thank everyone who has helped me realize many of the goals and aspirations that I set out to accomplish 1 year ago. Without the hard work and commitment of Eric Muehlbauer, the North American Spine Society (NASS) administrative staff, and every NASS member who has worked individually or through our committees, very little could have been accomplished this year. To every one of you who has taken the time and made the effort to allow NASS to exceed everyone’s expectations, I thank you sincerely. I would also like to thank Terre Hall, the executive director of the Center for Patient Advocacy. She has taken what was once a dream for me and turned it into one of the most powerful grassroots advocacy groups in Washington. It has been a great honor and certainly the highlight of my professional career to lead NASS into the twenty-first century. When I became president of NASS, I had planned that the time I am spending with you today would be spent looking into the future and predicting what medical and scientific revelations we might look forward to. After all, just look where we began. Who would have even dared to dream at the turn of the last century that we would be able to reconstruct the most severe spinal deformity; diagnose almost any pathologic condition of the spine, bony or otherwise, noninvasively; increase the speed and success of a spinal fusion with electrical stimulation, bone morphogenic proteins (BMPs), bone substitutes, and soon, genetic engineering! Who could have imagined that modern technology would enable us to operate on the spine arthroscopically through a mere puncture wound when at the outset of the last century it would be almost 35 years before the first discectomy would be reported in the medical literature. Who could have dreamed that we could repair congenital spine defects in utero. As we look to the next century of spine care, nothing can hold us back from realizing even greater scientific and clinical accomplishments, other than our lack of innovation, creativity, and imagination. However, I would like to not only look to the future, but also to the past for guidance by going back to basics.
* Corresponding author. 2445 Army Navy Dr., Arlington, VA 22206
It has been almost 20 years since I finished my fellowship and embarked on my career in spine care. During this relatively short period, I have seen extraordinary scientific and clinical advances in our ability to diagnose and treat patients with spinal disorders. Unfortunately, we have also seen changes that are far less extraordinary. I can still remember when at a NASS meeting the most talked about topic in the hallways was research, not reimbursement; when I was more interested in attending a lecture on basic science, not practice management; when I would have preferred to enroll in a course on the latest surgical techniques, rather than CPT coding. While living in Washington for the last 10 years, I have not only had the privilege to serve on the NASS board, but I have also become involved in the politics of health care. Unfortunately, today in Washington health care is politics. I once thought people cared and listened to what doctors had to say. I have come to realize that as physicians our thoughts and actions do change people’s lives daily, but outside our little world, no one listens much anymore and we are not nearly as powerful as we think we are. In the recent past when faced with passing legislation supported by the physicians and medical societies, or by passing legislation supported by insurance companies, big business, or the trial lawyers, to whom have our elected officials listened? As a member of a congressionally appointed committee on Medicare reimbursement policy and one of the few practicing physicians on the committee, I know firsthand that the voice of the practicing physician has the least, if any, impact on changes in Medicare policy. When it comes to quality patient care, what is becoming increasingly more important than what I think as a practicing physician is how much it will cost the federal government. When the Clinton health-care plan was defeated by the extensive lobbying efforts of the managed care companies, we all breathed a sigh of relief, thinking we were safe from federally regulated health care. But what the Clinton healthcare plan had proposed in a massive bureaucracy had taken place unregulated and almost overnight by the managed care industry. Does managed care really care what we think or say? Do they care whether we agree with their policy of who needs a magnetic resonance image? Do they really
1529-9430/01/$ – see front matter © 2001 Elsevier Science Inc. All rights reserved. PII: S1529-9430(01)00 0 0 4 - 3
6
2001 Presidential Address / The Spine Journal 1 (2001) 5–7
want to hear what we have to say about who is allowed to undergo surgery? You bet they do, but only if it improves their year-end bottom line. If we have so much power to impact the life of a single patient, then why do we have so little impact on our ability to practice medicine as we see fit, or provide what we think is the best quality spine care? Why is it that once we leave the examining room, no one, whether it’s the politicians in Washington, Medicare, or the insurance industry, really cares what we think? The answers to these questions are not simple and certainly not straightforward. For decades, US physicians thought of themselves as unique, having a role in a democratic and capitalist society unlike any other profession or trade. We were the trustees of health and well-being, life and death, and were simply immune to the rules by which the rest of corporate America had to abide to survive and thrive in the world’s most competitive free market economy. After all, through most of the past century, haven’t we been able to practice independently and freely, and in most cases with great financial success? But slowly the cost of health care began to outpace all other aspects of US life. It started to become apparent that certain groups of US citizens could no longer afford quality health care. The fact was that we physicians were living the American dream. The problem was that many of our fellow US citizens, when it came to having access to health care, were not. Elderly US citizens were the first to fall through the cracks. Medicare was created to insure that all US citizens over the age of 65 would be guaranteed quality health care and remain part of the US health-care dream. It wasn’t too long before the politicians realized that we couldn’t pay doctors to care for Medicare patients what they had been paid to provide the same care before.
Neil Kahanovitz, MD
Next we found ourselves facing DRGs. Before long DRGs led to health management organizations and then the onslaught of managed care. With that I welcome you to the world of health care at the turn of the twenty-first century, not a comfortable or reassuring place to be for either the US doctor or patient. I often ask myself where we went wrong. Through the 1970s, 1980s, 1990s as corporate America and our politicians in Washington were changing with the times, should we have paid more attention to the world around us, or continued as we did to think of ourselves as different and immune to the rules of corporate America? Should we have joined forces and formed a union to protect our patients and ourselves? Every other group of US workers has done so to protect their rights against the greed of corporate America. But back then we thought that the US doctor would never be treated like an ordinary employee. So why bother, we’re doctors, we can always practice exactly as we see fit. No one could ever take that away from us. Besides we had the traditional medical societies to protect us if we ever needed protecting. Almost every one of us belongs to such traditional societies as the American Academy of Orthopedic Surgens (AAOS) and the American Association of Neurological Surgery (AANS). Haven’t they protected us from the wrath of managed care and the regulatory backlash of the federal government? Unfortunately, none of us has the real answer to the question of how we ended up where we are today. However, that doesn’t mean we can’t learn from our past experiences and behavior. The first lesson to learn, and for many of us the hardest to accept, is that we are not that special. Certainly, no more special than the computer experts who have changed the world of communication and commerce. No more special than the genetic scientists who have figured out the human genome or the engineers who have made space exploration a way of life. There is one thing that makes us unique compared with all the other highly talented and technical professionals in today’s world. That one quality goes back to the very reason that most of us chose to become physicians. What makes us so unique is our ability to single-handedly prevent the suffering, improve the quality of life, and save the life of a fellow human being. We alone have this power. Unfortunately, through our shortsightedness, naiveté, and oftentimes arrogance, we have in many instances lost our ability to exert this power in a way that best serves our patients. Then how can we get it back? Let’s first look at how an organization such as NASS can begin to change the way that the traditional medical societies serve their members in our ever-changing world of socioeconomics, politics, and medicine. Fifteen years ago, NASS was established by several members of the International Society for the Study of the Lumbar Spine as a less restrictive society that would allow anyone with a practice in spine care to participate in an annual meeting. As we sit here at our fifteenth meeting, we are participating in the most prestigious and well-attended multispecialty spine program held anywhere in the world. But with this growth and the increasing sophistication of the
2001 Presidential Address / The Spine Journal 1 (2001) 5–7
scientific papers presented at each year’s meeting, it is critical for us to understand that the role of any medical society is not just hosting an annual meeting or providing an educational forum for its members. It became clear to many of us that NASS, unlike many of its medical society predecessors, needed to improve the accessibility of quality spine care for our patients. It has become our mission and our duty to not only present the latest in scientific accomplishments to our members, but to defend our ability to care for our patients when that is threatened. In recent years we have not backed away, and in many instances we have stood alone in facing what appeared to be insurmountable battles with formidable opponents. The first time that NASS ventured outside the traditional boundaries of the US medical society was in the mid 1990s. A federal agency, the Agency for Health Care and Policy Research (AHCPR), was in the process of formulating guidelines that were to be used as a guidance document by Medicare to determine which diagnostic studies and treatment were appropriate for patients with acute low back pain. The most disturbing part of this process was that despite the fact that this was a federally funded project with our tax dollars, the entire process was done in private without any input from any individuals or societies other than those invited by the agency. It was the position of NASS that this closed-door policy violated not only the spirit of free academic exchange but also, more importantly, the very essence of an open democracy. With the help of countless members around the country, the voice of NASS was heard in Washington. Not only was the budget of this agency slashed by the politicians in Washington once they were educated by members of NASS concerning the inappropriateness of this process, but in the following year, the AHCPR announced that they would never again be involved in the formulation of clinical guidelines. Since then, the AHRQ, the former AHCPR, has been working closely with NASS, particularly in the area of federal attempts to reform medical errors. Why has this new alliance developed between two previous enemies? The answer is simple. NASS members fought publicly for what they knew was right and just for the patients they care for. Now this federal agency is in a similar fight to prevent the unnecessary regulation of medical practice, and they have asked for our help and allegiance, because they know that NASS will fight for what is best for the American patient. We have been no less successful in our battles with the plaintiffs attorneys when NASS and its members were unjustly attacked in the well-known and publicized pedicle screw fiasco. When other larger medical societies and a manufacturer of pedicle screws were willing to compromise and give in to the demands of the plaintiffs, attorneys, NASS stood firm in its belief that the society in general, and our members in particular, had done nothing other than provide state-of-the-art spinal instrumentation to our patients. In the end our tireless efforts were rewarded, and today our
7
patients are still able to reap the benefits of the best treatment options we as physicians felt they deserved. These efforts, which certainly go far beyond the traditional boundaries and activities of medical societies, must and should continue. Our work in the CPT arena is just another example of the proactive approach to improving our patient’s access to state-of-the-art spine care. I can tell you that none of these remarkable achievements could have occurred without the support of the membership of NASS and their ability to see clearly what is in the best interests of their patients. How can we improve how we care for patients? It should be perfectly clear to all of us that as individuals we have lost our voice in the changing US health-care system. So who will speak for us now and be heard? The voice of effective medical reform in this county can come from only one source: our patients. The overwhelming changes in managed care have made it increasingly difficult for patients to find a doctor who not only will take the time to talk with them but who will care about their problems. Managed care has been a burden not only for patients, but also for physicians. Decreased reimbursement, increased bureaucracy, and paperwork have led to increased patient volumes and less time for patient contact. The ability to care adequately and compassionately for patients is becoming more and more difficult. More doctors are retiring and leaving medicine at a younger age than ever before simply because they can no longer care for patients as they once thought appropriate. As dismal as this picture appears, there is light on the horizon. Just look at this election year’s most hotly debated topics: managed care reform and access to prescription drugs for our elderly. Why are these the most widely debated topics? Not because doctors across the country have cried out for reform, but because our patients across the country have demanded that something be done to improve the state of their health care. No one really cares what we think, but they surely care what our patients think and want. Our patients can improve this rapidly deteriorating health-care delivery system, but they can’t do it without our help, and the best way to help them is to do what we set out to do when we made the decision to become physicians. That is simply treating our patients as we would want to be treated ourselves. Take the time to answer their questions. Remember why we became physicians in the first place. Our only hope of reform is for our patients to take up the cause and have their voices heard. Our patients have nowhere to turn for help. They have been forsaken by the insurance companies, and they have lost faith in the federal government. It is now more important than ever that they can count on us to provide them with the medical care that they deserve. If we do, I know that the light that is just beginning to dawn on the horizon may one day shine brightly on an American health-care system that we can once again be proud of. But we can’t do it by ourselves, and we certainly can’t do it if we continue to live in our own little world of isolation.
North American Spine Society 2000 Presidential Address Neil Kahanovitz, MD* I would truly like to thank everyone who has helped me realize many of the goals and aspirations that I set out to accomplish 1 year ago. Without the hard work and commitment of Eric Muehlbauer, the North American Spine Society (NASS) administrative staff, and every NASS member who has worked individually or through our committees, very little could have been accomplished this year. To every one of you who has taken the time and made the effort to allow NASS to exceed everyone’s expectations, I thank you sincerely. I would also like to thank Terre Hall, the executive director of the Center for Patient Advocacy. She has taken what was once a dream for me and turned it into one of the most powerful grassroots advocacy groups in Washington. It has been a great honor and certainly the highlight of my professional career to lead NASS into the twenty-first century. When I became president of NASS, I had planned that the time I am spending with you today would be spent looking into the future and predicting what medical and scientific revelations we might look forward to. After all, just look where we began. Who would have even dared to dream at the turn of the last century that we would be able to reconstruct the most severe spinal deformity; diagnose almost any pathologic condition of the spine, bony or otherwise, noninvasively; increase the speed and success of a spinal fusion with electrical stimulation, bone morphogenic proteins (BMPs), bone substitutes, and soon, genetic engineering! Who could have imagined that modern technology would enable us to operate on the spine arthroscopically through a mere puncture wound when at the outset of the last century it would be almost 35 years before the first discectomy would be reported in the medical literature. Who could have dreamed that we could repair congenital spine defects in utero. As we look to the next century of spine care, nothing can hold us back from realizing even greater scientific and clinical accomplishments, other than our lack of innovation, creativity, and imagination. However, I would like to not only look to the future, but also to the past for guidance by going back to basics.
* Corresponding author. 2445 Army Navy Dr., Arlington, VA 22206
It has been almost 20 years since I finished my fellowship and embarked on my career in spine care. During this relatively short period, I have seen extraordinary scientific and clinical advances in our ability to diagnose and treat patients with spinal disorders. Unfortunately, we have also seen changes that are far less extraordinary. I can still remember when at a NASS meeting the most talked about topic in the hallways was research, not reimbursement; when I was more interested in attending a lecture on basic science, not practice management; when I would have preferred to enroll in a course on the latest surgical techniques, rather than CPT coding. While living in Washington for the last 10 years, I have not only had the privilege to serve on the NASS board, but I have also become involved in the politics of health care. Unfortunately, today in Washington health care is politics. I once thought people cared and listened to what doctors had to say. I have come to realize that as physicians our thoughts and actions do change people’s lives daily, but outside our little world, no one listens much anymore and we are not nearly as powerful as we think we are. In the recent past when faced with passing legislation supported by the physicians and medical societies, or by passing legislation supported by insurance companies, big business, or the trial lawyers, to whom have our elected officials listened? As a member of a congressionally appointed committee on Medicare reimbursement policy and one of the few practicing physicians on the committee, I know firsthand that the voice of the practicing physician has the least, if any, impact on changes in Medicare policy. When it comes to quality patient care, what is becoming increasingly more important than what I think as a practicing physician is how much it will cost the federal government. When the Clinton health-care plan was defeated by the extensive lobbying efforts of the managed care companies, we all breathed a sigh of relief, thinking we were safe from federally regulated health care. But what the Clinton healthcare plan had proposed in a massive bureaucracy had taken place unregulated and almost overnight by the managed care industry. Does managed care really care what we think or say? Do they care whether we agree with their policy of who needs a magnetic resonance image? Do they really
1529-9430/01/$ – see front matter © 2001 Elsevier Science Inc. All rights reserved. PII: S1529-9430(01)00 0 0 4 - 3
6
2001 Presidential Address / The Spine Journal 1 (2001) 5–7
want to hear what we have to say about who is allowed to undergo surgery? You bet they do, but only if it improves their year-end bottom line. If we have so much power to impact the life of a single patient, then why do we have so little impact on our ability to practice medicine as we see fit, or provide what we think is the best quality spine care? Why is it that once we leave the examining room, no one, whether it’s the politicians in Washington, Medicare, or the insurance industry, really cares what we think? The answers to these questions are not simple and certainly not straightforward. For decades, US physicians thought of themselves as unique, having a role in a democratic and capitalist society unlike any other profession or trade. We were the trustees of health and well-being, life and death, and were simply immune to the rules by which the rest of corporate America had to abide to survive and thrive in the world’s most competitive free market economy. After all, through most of the past century, haven’t we been able to practice independently and freely, and in most cases with great financial success? But slowly the cost of health care began to outpace all other aspects of US life. It started to become apparent that certain groups of US citizens could no longer afford quality health care. The fact was that we physicians were living the American dream. The problem was that many of our fellow US citizens, when it came to having access to health care, were not. Elderly US citizens were the first to fall through the cracks. Medicare was created to insure that all US citizens over the age of 65 would be guaranteed quality health care and remain part of the US health-care dream. It wasn’t too long before the politicians realized that we couldn’t pay doctors to care for Medicare patients what they had been paid to provide the same care before.
Neil Kahanovitz, MD
Next we found ourselves facing DRGs. Before long DRGs led to health management organizations and then the onslaught of managed care. With that I welcome you to the world of health care at the turn of the twenty-first century, not a comfortable or reassuring place to be for either the US doctor or patient. I often ask myself where we went wrong. Through the 1970s, 1980s, 1990s as corporate America and our politicians in Washington were changing with the times, should we have paid more attention to the world around us, or continued as we did to think of ourselves as different and immune to the rules of corporate America? Should we have joined forces and formed a union to protect our patients and ourselves? Every other group of US workers has done so to protect their rights against the greed of corporate America. But back then we thought that the US doctor would never be treated like an ordinary employee. So why bother, we’re doctors, we can always practice exactly as we see fit. No one could ever take that away from us. Besides we had the traditional medical societies to protect us if we ever needed protecting. Almost every one of us belongs to such traditional societies as the American Academy of Orthopedic Surgens (AAOS) and the American Association of Neurological Surgery (AANS). Haven’t they protected us from the wrath of managed care and the regulatory backlash of the federal government? Unfortunately, none of us has the real answer to the question of how we ended up where we are today. However, that doesn’t mean we can’t learn from our past experiences and behavior. The first lesson to learn, and for many of us the hardest to accept, is that we are not that special. Certainly, no more special than the computer experts who have changed the world of communication and commerce. No more special than the genetic scientists who have figured out the human genome or the engineers who have made space exploration a way of life. There is one thing that makes us unique compared with all the other highly talented and technical professionals in today’s world. That one quality goes back to the very reason that most of us chose to become physicians. What makes us so unique is our ability to single-handedly prevent the suffering, improve the quality of life, and save the life of a fellow human being. We alone have this power. Unfortunately, through our shortsightedness, naiveté, and oftentimes arrogance, we have in many instances lost our ability to exert this power in a way that best serves our patients. Then how can we get it back? Let’s first look at how an organization such as NASS can begin to change the way that the traditional medical societies serve their members in our ever-changing world of socioeconomics, politics, and medicine. Fifteen years ago, NASS was established by several members of the International Society for the Study of the Lumbar Spine as a less restrictive society that would allow anyone with a practice in spine care to participate in an annual meeting. As we sit here at our fifteenth meeting, we are participating in the most prestigious and well-attended multispecialty spine program held anywhere in the world. But with this growth and the increasing sophistication of the
2001 Presidential Address / The Spine Journal 1 (2001) 5–7
scientific papers presented at each year’s meeting, it is critical for us to understand that the role of any medical society is not just hosting an annual meeting or providing an educational forum for its members. It became clear to many of us that NASS, unlike many of its medical society predecessors, needed to improve the accessibility of quality spine care for our patients. It has become our mission and our duty to not only present the latest in scientific accomplishments to our members, but to defend our ability to care for our patients when that is threatened. In recent years we have not backed away, and in many instances we have stood alone in facing what appeared to be insurmountable battles with formidable opponents. The first time that NASS ventured outside the traditional boundaries of the US medical society was in the mid 1990s. A federal agency, the Agency for Health Care and Policy Research (AHCPR), was in the process of formulating guidelines that were to be used as a guidance document by Medicare to determine which diagnostic studies and treatment were appropriate for patients with acute low back pain. The most disturbing part of this process was that despite the fact that this was a federally funded project with our tax dollars, the entire process was done in private without any input from any individuals or societies other than those invited by the agency. It was the position of NASS that this closed-door policy violated not only the spirit of free academic exchange but also, more importantly, the very essence of an open democracy. With the help of countless members around the country, the voice of NASS was heard in Washington. Not only was the budget of this agency slashed by the politicians in Washington once they were educated by members of NASS concerning the inappropriateness of this process, but in the following year, the AHCPR announced that they would never again be involved in the formulation of clinical guidelines. Since then, the AHRQ, the former AHCPR, has been working closely with NASS, particularly in the area of federal attempts to reform medical errors. Why has this new alliance developed between two previous enemies? The answer is simple. NASS members fought publicly for what they knew was right and just for the patients they care for. Now this federal agency is in a similar fight to prevent the unnecessary regulation of medical practice, and they have asked for our help and allegiance, because they know that NASS will fight for what is best for the American patient. We have been no less successful in our battles with the plaintiffs attorneys when NASS and its members were unjustly attacked in the well-known and publicized pedicle screw fiasco. When other larger medical societies and a manufacturer of pedicle screws were willing to compromise and give in to the demands of the plaintiffs, attorneys, NASS stood firm in its belief that the society in general, and our members in particular, had done nothing other than provide state-of-the-art spinal instrumentation to our patients. In the end our tireless efforts were rewarded, and today our
7
patients are still able to reap the benefits of the best treatment options we as physicians felt they deserved. These efforts, which certainly go far beyond the traditional boundaries and activities of medical societies, must and should continue. Our work in the CPT arena is just another example of the proactive approach to improving our patient’s access to state-of-the-art spine care. I can tell you that none of these remarkable achievements could have occurred without the support of the membership of NASS and their ability to see clearly what is in the best interests of their patients. How can we improve how we care for patients? It should be perfectly clear to all of us that as individuals we have lost our voice in the changing US health-care system. So who will speak for us now and be heard? The voice of effective medical reform in this county can come from only one source: our patients. The overwhelming changes in managed care have made it increasingly difficult for patients to find a doctor who not only will take the time to talk with them but who will care about their problems. Managed care has been a burden not only for patients, but also for physicians. Decreased reimbursement, increased bureaucracy, and paperwork have led to increased patient volumes and less time for patient contact. The ability to care adequately and compassionately for patients is becoming more and more difficult. More doctors are retiring and leaving medicine at a younger age than ever before simply because they can no longer care for patients as they once thought appropriate. As dismal as this picture appears, there is light on the horizon. Just look at this election year’s most hotly debated topics: managed care reform and access to prescription drugs for our elderly. Why are these the most widely debated topics? Not because doctors across the country have cried out for reform, but because our patients across the country have demanded that something be done to improve the state of their health care. No one really cares what we think, but they surely care what our patients think and want. Our patients can improve this rapidly deteriorating health-care delivery system, but they can’t do it without our help, and the best way to help them is to do what we set out to do when we made the decision to become physicians. That is simply treating our patients as we would want to be treated ourselves. Take the time to answer their questions. Remember why we became physicians in the first place. Our only hope of reform is for our patients to take up the cause and have their voices heard. Our patients have nowhere to turn for help. They have been forsaken by the insurance companies, and they have lost faith in the federal government. It is now more important than ever that they can count on us to provide them with the medical care that they deserve. If we do, I know that the light that is just beginning to dawn on the horizon may one day shine brightly on an American health-care system that we can once again be proud of. But we can’t do it by ourselves, and we certainly can’t do it if we continue to live in our own little world of isolation.