Neurology in Crisis

February 2, 2013

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Dr. Bruce Sigsbee

Today, I am issuing a call to action.

Decisions made in Washington increasingly impact the day-to-day practice of neurology. To overcome the pressures of the crushing national debt and threats to medicine, we need extraordinary political pressure to succeed. As a member of the AAN, you need to get involved.

We all know that medicine—and neurology in particular—has struggled the past few years. Compared to other specialties, our reimbursement is low. As a result, only about 60 percent of residency positions are filled with graduating US medical student seniors. I personally know several students who preferred neurology but chose other specialties due to a high educational debt burden.

The substantial cut to nerve conduction reimbursement has aggravated the problems. These cuts were announced without any notice and no ability to comment on the unintended consequences. Private practices, groups, and academic departments have depended on the neurophysiology revenue to offset the low payment for evaluation and management (E/M) services.

I feel like neurology was singled out, and to some extent we were. Other high-volume outpatient diagnostic services are not being hit, though they may be in the next few years. Part of the problem is those outside the traditional practices of electrodiagnostic medicine, such as other specialties and even the mobile nerve conduction labs, have driven up the volume and attracted the attention of CMS. We are doing everything we can to at least reduce the magnitude of the cuts. At present, based on the statements of CMS, nothing is likely to happen this year, but there is hope for 2014. Private payers are very likely to adopt the CMS reductions.

Unfortunately, further cuts are likely. The federal government has had a 40-percent deficit over the past four years. In other words, 40 percent of the federal budget is based on borrowed money. Some argue that the only way to fix the budget is with cuts that would result in a 40-percent cut to Medicare and Medicaid—two items that make up over 25 percent of the federal budget. Growth in the economy of 5-6 percent, a fantastic growth rate, will not make up for the deficit. Tax increases beyond the current increase for the wealthiest are politically unrealistic and would not make up for the difference. Entitlements (Medicare, Medicaid, and Social Security) plus the debt service currently make up 60 percent of the federal budget. To fix the deficit, which has to be done, will require further cuts to Medicare.

The recent temporary prevention of the Medicare SGR cuts was "paid for" by reductions in imaging and hospital payments. Hospitals in particular are angered that they are paying for the doctors. Just about every accounting mechanism to temporarily fix the SGR has been used. Again, cuts to Medicare are likely targets in the future.

Furthermore, we continue to struggle with government programs that require reporting on the use of electronic medical records, electronic prescribing and quality measures from the Centers for Medicare & Medicaid Services, all of which will turn to penalties in the next few years. By the way, there is insufficient evidence that these steps lower cost or improve quality.

Where does this leave neurology? There are very real threats to the specialty and patient access to neurologic expertise. Not long ago, Bob Doherty, senior vice president for governmental affairs and public policy for the American College of Physicians, predicted the demise of internal medicine if relief was not provided. While perhaps not as dire, the number of neurologists is at risk of decreasing. We are confronting the same problems of current and greater deficits in the required number of neurologists and the challenges of attracting US graduates into the specialty. Training programs are considering a reduction in slots. I have heard from a number of colleagues, particularly in small rural practices, that they can no long hold on and are closing. The barriers to those wishing to enter an academic career are huge and getting larger. Further cuts only will aggravate the problems.

These threats come at a time with there is real promise for effective treatments for neurologic disease such as Alzheimer's. With the aging population, the financial burden on families and the health care system are real threats to the country. Access to neurologic care and research to extend the recent discoveries is critical to the nation.

We are having success. If it were not for the debt issue, we already would have solved the lack of payment for neurologic E/M services. So, again, I issue a call to action.

Contact your delegation to Washington and let them know what is happening. They may not care about your income, but they are worried about constituents' access to quality services and a balanced workforce. Nearly every member of Congress I speak to has a personal neurologic problem or is close to someone who has benefited from neurologic expertise. With all the competing demands on federal resources, they need to hear from us. They need to hear from you.

Please help the AAN. Respond to Action Alert requests from our public policy staff and tell your story to members of Congress. The AAN cannot do this alone for you or your patients.

Bruce Sigsbee, MD, FAAN
President, AAN