0:02
SNI Digital, Innovations in Learning, a new 3D Live video journal, which is interactive with discussion of all of its topics
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in association with SNI surgical neurology, international A2D internet journal,
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is pleased to present another in the SNI digital series and controversies in medicine, this one being healthcare and crisis. The topic of this program is neurosurgery and crisis, how central
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control and socialization is destroying the practice of medicine with testimonials from neurosurgeons. This is part one of a series
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the introduction of healthcare in 1965 in the United States. The practice of medicine has undergone the progressive central control of healthcare, rising costs, declining ease of access, failing
1:09
quality of care, a shortage of physicians, and patient dissatisfaction.
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A change from the doctor patient free market model to a government biomedical industry socialized model has led to overwhelming patient and physician dissatisfaction and to distorted medical
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incentives, which have led to a failing healthcare system and is similar in other countries around the world. This impending healthcare disaster is not discussed by political parties
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in the United States or by organized medicine. Why? Yet everyone sees its failure. What needs to be done?
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SI and SI digital will be interviewing members of the parties involved in delivering health care in the USA to develop a solution to this desperate health care crisis in the USA and perhaps elsewhere.
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What are the facts? What is the truth? If you're interested in participating in this effort and want to be part of its meetings, please send your name, your email address and contact number
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to jameshousemanmaccom. The discussants in this meeting are Strata
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Bernard from her head of neurosurgery at the University of North Carolina, subsequently in private practice in Anchorage, Alaska.
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Ramses Gali, a board certified neurosurgeon, with also boards in anesthesia critical care and pain medicine, who is the CEO of Gali Neurosurgical Associates in Aurora, Illinois.
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Jay Morgan, who is the CEO of the Sierra Neurosurgery Group in Reno, Nevada, the president-elect of the Nevada Medical Association in 2026 and former president of the Western Neurosurgical
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Association
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And Eric Nussbaum, formerly of the University of Minnesota Neurosurgery Faculty,
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and now subsequently at the CEO of the National Brain Aneurysm and Tumor Center in Minneapolis, St. Paul, Minnesota. The moderator is James Osmond.
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I'll tell you about Australia. Strata is,
3:48
I'm sorry, Mr. Jay. She's a friend to Jay, been friends for a while Or strata was from How You Doing? There he is, hi. There he is. He was, his family from, originally from Liberia, came to
4:01
the US, worked at Duke with Bob Wilkins, which I
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think should tell you a lot, because first of all, back then he's about 89
4:16
years old, I think,
4:19
I'm kidding you. So it was early in medicine when we all were growing up and Bob was a very respectable person He worked at Duke, which was a very respectable institution. Bob asked him to stay on
4:31
in the faculty, stayed there for a while, I went to
4:36
University of North Carolina, is that right? Yeah, UNC Chapel Hill, yeah. Yeah, UNC Chapel Hill. Not sure where to read the way I got to UNC was that they were recruiting Alan Friedman to be
4:50
chief of neurosurgery there, I'm Alan Asrin to join him on the faculty. And so I took a look at it, but then Alan decided to stay at Duke. And, but I liked while I saw a UNC. So I went to UNC.
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That's great. So anyway, he went there, which I headed the department for a while, and then left this, this will ring with you, Eric, and left you going to private practice and went to Alaska.
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What does that tell you?
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I want to get as far away from American medicine as I can, and still be not. Alaska was the last frontier, but it's begun to fall, right before I left, it was falling in line with the rest of the
5:36
country. Yeah, so, yeah, I mean, it's really, all you do is say that, you know everything you need to know. And Eric, it's Eric Nussbaum, Eric was, he went, you went to Maryland, didn't
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you? Medical school, yeah Yeah, I went to Maryland. Would you grow up in
5:57
the Northeast? I mean, New York down to Baltimore corridor? Yeah, okay, that's where you grew up. So, and he's married to a physician just like you are, Australia. His wife went into
6:08
neurosurgery and is in
6:12
actually radiation therapy or radiation. And
6:19
so they've been together for a long time. He established a very, he was at the University of Minnesota, that's where I was. And then we were a few years apart. And I left a little earlier. And
6:35
it just wasn't, they were going through the transition to one of the predictors was very successful, had his own practice, which was multidisciplinary, and did very well, but has -
6:52
And his medicine has grown more centralized with loss of private practice. He's in the older group of people, not as old as I am, but he's
7:07
got some interesting perceptions. And so that's Eric and Jake, can you hear us? Yeah, I can, can you hear me? Yeah, I just did a hemorrhagic spinal cord tumor and fix the cervical spine. And
7:23
now I got a T5 fracture, I got a fix. Your practice has how many neurosurgeons in it? We have six, soon to be seven. And you had a bigger group before, right? Yeah, we had 10. And he went to
7:38
Reno and so how is it impacting your guys? What do they think, what's going on?
7:48
Well, Medicare is reducing their rates and we're 30.
7:53
maybe even 40 Medicare at this point in time. So obviously we have to work harder to make the same dollar. Nurse practitioners are expensive and we have nurse practitioners and PAs. In fact, we
8:07
have, I believe 12, including our two for our pain management docs. And
8:14
we have to keep up with them and it was a little bit difficult during COVID because the hospitals were paying a lot of money
8:22
And we had to keep up with that. And then just the front desk to building and coding,
8:29
all those people during COVID, they had the opportunity right after COVID, had the opportunity to make a lot more money and the VA was paying front desk people about3 more than us. So we had a very
8:43
difficult time getting people to stay and good people to grow with us. That's changed to some degree Um increased competition in the community. We've had a couple of people break off from our group.
8:59
One of them is joined the North PETA group and orthopedics and neurosurgery seems to work together. It's two groups in town are working together with orthopedists. A lot of people have focused on
9:12
spine and there's a lot of information out now. I just saw in Doc's imagery about over
9:21
operating on spinal cases, but we've also focused on cranial as well as functional, which we're expanding into. But those things aren't reimbursed as well. So overhead's gone up, reimbursements
9:37
have gone down. Our malpractice have also increased because we had cap on our malpractice for 20 years. And the lawyers just
9:51
said that was too much.
9:53
the cap, but we were able to raise the cap a little bit more than doctors like, but less than the lawyers liked. But that was a fight within the legislative session. And we went to that
10:07
now two years ago.
10:10
So our rates are raising, although the insurance companies were pretty happy because there is a limit. And the lawyer said they were going to wait for 10 years
10:20
You know, it takes to get approval also, I mean, I think just to run the gamut, to get approval on the case, we've got to go through hoops and we have to pay people to do that. We have to get on
10:32
the phone and talk to people about what we think is a right procedure for patients, which costs us money and we're not really talking to physicians. But you know, if you give them respect, a lot
10:43
of times they'll help you out with that And I think the other thing is we are seeing people creep into our space. So for instance, and I'll stop here, pain management doctors in town are doing a
10:58
zip procedure where they're using decompressive laminectomy codes and fusion codes which we use to do an outpatient procedure where they make a small incision. I don't know what they do between the
11:10
spinous processes but there's an inner spinous clamp and they're drilling some bone and they're using all these codes. Now, if it's just like chiropractic codes, I mean, if you've got pain
11:22
management people doing thousands of these codes, then spine surgeons look like do do. You know what I mean? So we're obviously operating and overcharging and blah, blah, blah, when, you know,
11:34
we're doing cases that, you know, may take a lot longer and we're doing bonafide cases. Wow, that's a big guy. I didn't know that from you before. I don't see it because of time I just want to
11:44
get you some input before you work. Eric, can you tell us?
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because Jay and Estrad and I, we talk and Jay and Estrad, Jay knows Estrad a well and so forth, but they don't know what your circumstances can you tell everybody, you got some time, you okay,
12:05
Jay? Yeah. What's impacting you now? What's going on? Well, I mean, I think it's probably, so my practice is interesting because I've always been just a complex cranial neurosurgeon. So
12:18
vascular and skull base has been what I've done my whole career is at the University and the full-time faculty here at the University of Minnesota for the first six years or so. And then I started a
12:28
private practice kind of paradoxically because I wanted to be more sub-specialized. And at the university here, when I was on call, there was a requirement that you staff all cases so that if a
12:41
patient came in with a, you know, thoracic fracture, like what you're gonna do there, I was, I never trained to do that work. We didn't do real instrumentation when I was training. And yet now
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I'm on the faculty and the expectation was that the chief resident would do the case and I would staff it and I was uncomfortable with it. And I just wanted to do what I felt like I was good at. So
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I've been in practice in the Twin Cities for about 25 years. And I mean, probably have seen a lot of the same changes that you guys have seen. But I mean, I wrote out a list here of the things
13:13
that have gone wrong. So the first thing was, and I think it's more than just from my perspective, random. I think this has been planned But so number one, you get the declining reimbursements in
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a big way so that we're making less. Number two is the increasing overhead for all the things that you were talking about. I mean, not just the prior authorizations and not just having to deal with
13:37
the nurse practitioners and PAs and paying their increasing salaries, but the time that you have to spend to collect for the work that you've done because he insurance companies. you know, really
13:52
started routinely denying the claims and requiring a lot of time spent, you know, talking to people to try to get paid for the work that we did and oftentimes being under reimbursed for the work we
14:06
did. And then I think the next thing that kind of came into play was this, I mean, what we've seen is the addition of these layers of bureaucracy within the hospitals, making it, you know, early
14:19
on, I had very good relationships developing our programs. It aligned very much with the hospital systems here that I was working with in the Twin Cities. And all of a sudden you have these layers
14:31
of bureaucracy and our interests are no longer aligned so that the idea wasn't to provide any more high quality care with good outcomes, but everybody wants to make money, I think. I mean,
14:44
everybody wants to be cost efficient, But the hospitals seem to stop having that as they're goal and focus. So all of a sudden, they're worried about other things. They're worried about, for
14:56
example, trying to capture the
15:02
young people who need a one-level lumbar laminectomy or a lumbar microdiscectomy,
15:09
which was going out to an ambulatory surgery center, trying to get those patients back. And they're a lot less interested in being involved with the higher complexity cases and having a center of
15:19
excellence. So that's been a challenge, you know, from my perspective, and I think there's been a kind of a, you know, an intentional devaluing of high-quality independent physicians so that
15:37
there's very much a desire to view physicians really as a cog, you know, in a machine and an interchangeable cog so that I, it's been my sense that the hospitals and the health care systems. have
15:49
been more uncomfortable with, you know, people like neurosurgeons higher in sub-surgical sub-specialists who,
15:57
you know, maybe have a more unique practice and have more control over bringing patients to the hospital. I don't think they like that. They tried to close ranks in higher positions and close the
16:10
system so that 10 years ago, as an aneurysm surgeon, I mean, I had patients coming from all the different systems in the twin cities and in the five state and eight state region being referred in.
16:24
And then they, you know, these health care systems hired a neurosurgeon until them know you're going to have to deal with it. And unfortunately, probably with the rise of endovascular, making it
16:33
a little bit easier,
16:35
you know, they just will, you'll have health care systems in hospitals that will treat, you know, three, four, five aneurysms a year, you know, which never used to happen, um, you know, and
16:46
so our numbers have come down, whereas we used to, I used to operate on 150 aneurysms a year and our endovascular folks would coil a similar number, you know, the numbers have really probably been
16:57
cut in half from there because the different health care systems have kind of carved that up. And so ultimately, I think it's kind of a pretty demoralizing situation at this point, at least here in
17:08
the Twin Cities, where the focus has kind of gone away from excellence and high quality care delivery, trying to do a good job for the patients in the hospital. And now they just want to employ
17:21
physicians. And the physicians who are my friends who've signed employment agreements are generally uniformly pretty unhappy because then it's all there's always a honeymoon period of three months
17:33
every year where everything's great until they start to ratchet down the salaries and make new demands and tell them they can't do this or they have to do that. All of a sudden, you know, I think
17:49
physicians who are pretty senior and who have worked very hard and care about their patients feel pretty demeaned. And so I think it's a tough time from my perspective. Just for everybody, for a
18:06
Stratus and Chase perspective, I don't have to say the name. And he'll tell why in just a minute But he had a colleague and friend he worked with for years and asked him to come to this meeting.
18:18
What happened? Well, I have to come to the meeting in particular to share an anecdote, very unfortunate anecdote he recently became employed. And he declined to come to the meeting because he was
18:30
afraid that if it were put on tape and his story were shared publicly that he could lose his new job And
18:40
he's 65 years old, really. I mean, I don't, you know, at the end of his clinical process, practice career probably, I mean, the last few years, but he needs the job and he needs the money at
18:51
this point. And he felt that there could be retribution if he, you know, I won't even share the incident because it could be traced back to him. But yeah, just something that, you know, again,
19:02
very demoralizing from my perspective to sort of be at a relatively senior point in your career where I think we have not been able to maintain, you know, the dignity that the profession, I mean,
19:21
I don't know how you guys feel. But I mean, I've always thought of neurosurgery as a calling and as the ultimate of the surgical subspecialties and medical disciplines. And I think that, you know,
19:32
we've really lost something. I can tell you this, the first notch. I remember when Roberto Herros was the chair at Minnesota. And I remember when he decided to leave. And you know, the reason
19:44
that he told me when I sat down with him privately and talked about it, he said that he had met with the Dean of the Medical School and the Dean of the Medical School said to him, We don't want any
19:56
stars. We want team players here. And I think that was sort of at the beginning of the end, even though it was a long time ago. And ultimately when I left the university, probably 10 years after
20:10
he had left, I mean, it was for similar, it was really for similar reasons that I ended up leaving. And I think it's only gotten worse. And not just, I mean, obviously, I mean, things change,
20:24
not just purely from an ego point of view that you want, you want to be a star, you want to be the most, but it's not that. But they really are attacked, they become attached to this idea that
20:34
the neurosurgeons and the different physicians should be completely interchangeable. And it doesn't matter who's on call It doesn't matter who does what. And I don't think any of us were trained
20:44
that way.
20:47
Okay, I think the one thing for all of us to recognize in Jay, I think this is something to take note of, you've got to go Jay, are you okay? Yeah, I think I'm getting ready to start, so. I
20:56
think one point before you leave is what Eric just told us, is that we're trying to get the truth. We're going to have a hard time for the reasons he just said. Oh yeah, I totally agree. Seeing
21:08
the same things and dealing with hospitals here. Okay, good Okay. Good luck. Okay. Good to see you. Good to see you. See you. Okay. Okay. Estrada, you got a perfect, you got a unique
21:19
perspective. You got, what did you see happening? Is it similar to, to what Eric was saying? Yeah, I think so. Jim, when I was at, when I was at the University of North Carolina, I realized
21:35
that the institution didn't appreciate my value. And what bothered me was that I felt like my destiny was being determined by people who didn't really understand what I was doing. And you had people
21:57
in blue suits who were getting oil compensated and making decisions that just weren't in the best interest of patient care. And I also realized that they they perceived that physicians were just cogs
22:17
in the wheel. I think Eric used that expression and you know that you could just be easily replaced. And I made the decision that I was going to change my situation so that I could I could be in a
22:33
place that values what I do that that would give me the autonomy to to pursue my interests unfettered. And Alaska provided a great opportunity to do that. Pretty much everything that I wanted to do,
22:52
they were willing to accommodate, I joined a neurosurgery group. They were at one point, we got up to six of us in the group. And it
23:08
worked out very well I said it was a last frontier because when I went there, we hadn't
23:16
been penetrated by managed care, in all of the disadvantages that come with that.
23:28
But eventually the managed care
23:34
did come into Alaska and that was the beginning of the end We. we.
23:42
we were forced to go into network and as is customer, as do you see with the employment models, they'll give you a reasonable deal up in the beginning, but then they'll start ratcheting you down
23:56
and we had absolutely no control. And that was concerning, it was demoralizing and
24:08
that eventually led to my retirement a couple of years ago, I mean, and
24:16
I mean, I love neurosurgery and I still love neurosurgery, but
24:21
just that the clinical practice just wasn't, wasn't as it, it just lost the luster that it had. There was just so many other things involved in the system that didn't facilitate good patient care.
24:40
And, you know, I moved from Alaska to Nevada and thought about maybe working part-time, but when I talked to people here, I realized that they were all just struggling. They're just on the
24:57
treadmill, increasing the speed of the treadmill because the reimbursements are going down,
25:09
the overhead is going up and I couldn't see myself getting back into that frame. I mean, I just certainly didn't need the money and but it was just for the intellectual stimulation that I was doing
25:25
it. But so many people were running around trying to get personal injury cases and that just wasn't appealing to me It was just a sign to me of where things have gone. And even as I've been on the
25:42
other side of the table, we've had a couple of friends in the local area that have had significant medical problems and just seeing how the whole system is so divided, everybody's working in silo.
25:57
There's poor communications with the family. I mean, I guess we sort of came up in the old school where you're just there and interacted with families and communicated with them and let them know
26:10
what's going on.
26:14
And if you needed to have a hematologist, you do a counsel and hematologist will come. These guys don't even have an incentive to come to the hospital to see their own patient. I mean, it's just
26:25
completely
26:27
blew me away. It's not something I've used to. Your patient is in the hospital and they call you and you say, I can't come to the hospital because of insurance business at work. Is that somebody
26:39
in your practice? I mean, it's just unbelievable. But
26:45
that's how
26:47
I see things, and that's been my exposure. That's excellent. It rams us, I know your microphone's off. He was just operating, I looked like dead. Tell everybody what you experienced, because I
27:01
think it's probably gonna be a repetition, but the extent of it is just alarming Yeah, so
27:09
it's actually. Start from the time you
27:17
were serving all these hospitals, and anesthesia, neurosurgery, and so forth. You had your own private practice, which was flourishing, right? Yeah, and this is what happened is, so I have
27:30
done food residency in anesthesia and neurosurgery An assigia for me was just something. I can do once a week to teach the resident and just to keep my foot wet into the field, that's it. And I was
27:46
able to do that and continue to do that until about 2007, 2008. And
27:53
then at that time, which is when the solo practice in Illinois starts to diminish and they start to employ people So at that time, I was a medical, I was a neurosurgery director and a neuroscience
28:11
director for the hospital. Which one? And Rush Cobbly and they promised me that
28:23
their dream is to make a neuroscience institute. So this is when I started there in about 2001 By 2004,
28:35
I was the very bad guy. And a very bad guy, because I was advocate of the patients. And they want to start to get the employment model started. Employment model means they will employ that
28:54
physician to work under them. And the name is no longer gonna be the name of Gali Neurosurgical Associates They will know more any names of neurosurgeon, just this name them, Rush Cobbly
29:10
Neurosurgery. So those evil people, what they have done overnight, they told me you're out, we cannot rent you that place. And the next day they change it to their name and they call it Rush
29:26
Cobbly Neurosurgery. And they employed neurosurgeons that nobody knows their names except the name of the institution itself.
29:36
Gradually, I still was able to survive because I had patients still, but then the hospital continued to have their own insurance, HMO, you have to sign with this advocate group, with this dryer
29:52
group, this dryer group, it has to use the employed neurosurgeons, so gradually the patient will want me, but they can't because the hospital starts to study and examine where these patients are
30:06
going to him, let's go ahead and make sure that these patients come to us. So by 2007,
30:14
I had to find my own clinic, which I did, and I both did, and then I start to get less patients, not because the patient don't want me, it's because they examined every patient go out of these
30:31
neurosurgeons, employ it, they will study why. and they will make sure that the next day the patient will come. Even if they threaten the patient by the primary physician, tell them you have to
30:44
stay in the system, you just name it. So, gradually, for me to survive, I had to do anesthesia. To do anesthesia, not as a hobby anymore, as neurosurge, anesthesia become mandatory to me
30:58
because anesthesia, that everybody thought, neurosurgeons makes good money for the work that he does. Now the unemployed neurosurgeon doesn't make much money because as Strada said, very
31:14
embarrassment is a real joke. So now I have to do anesthesia and to take calls until today, 2024, not because it's a hobby, it's in order to maintain my neurosurgery practice life And I am the
31:31
only one currently in the state of Illinois. that is unemployed neurosurgeon, that is unsupported by a hostile, no finance help, not from the government, not from taking calls, not from
31:46
referrals, and I get zero referrals from the hostile employee physicians, zero. I get zero referrals from the ER in the hospitals because the unemployed physicians neurosurgeon not allowed to take
32:04
calls. And the employed neurosurgeons, you can see them, they're drowned because they go to several hospitals when they're on call, they need help, two of them try to reach out to me, and to ask
32:20
for help and the husband said no, not employed neurosurgeons, do not allow to take calls. So every angle we try to get patients or try to help And then when they employ these neurosurgeons. This
32:34
neurosurgeon said, you know, Dr. Galli, I know you've been here for a long time. If you need any help or a round and all of the stuff, it took them two years. And then I reached out to them and
32:47
I said, can I use your help, your nurse, your nurse practitioner? Can someone check in that EVD? They said, we are not allowed. As an unemployed neurosurgeons, we cannot allow any help from
33:03
the employed neurosurgeon or the employed staff. And I said, why? They said it's because of medical legal reasons, whatever they can make up these things. So what actually happened? So in 2000
33:17
and the seven Rushcable Medical Center had three neurosurgeons only employed, that's it. And then now, so I had to start to work at another hospital called Central DuPage Hospital. I've been in
33:31
the staff there since 2003. And now, the employed neurosurgeons,
33:39
that they are all of them, except me, and another doctor named Matthew Ross. But Matthew Ross gets some help from the work done, or thanks. But as we talk, he said that he's having a hard time
33:52
to survive. So now, we need to make sure that to squeeze more this employed neurosurgeon to find them, to get the hell out of there So what they do,
34:06
they make it even more difficult. So now, the employed neurosurgeons cannot cover the unemployed neurosurgeon for the emergency contact in order to maintain privileges. So now, it has to be
34:20
unemployed neurosurgeon to cover the unemployed neurosurgeon. Otherwise, the neurosurgeon cannot be credentials. So this is the reason that when you talk to the hospitals, They tell you it's an
34:33
open stand. actually is a big lie. It's an open staff, but once you get in, there is no paperwork to give you, we don't need you, we don't want you, or you need to find another contact. And
34:47
this is really, this is really how they overcome all of that. So now talking about the survival, I used to have staff, I have no staff, I outsourced, and now the overhead, the malpractice in
35:04
the thousands of dollars is, you know, the transcription it takes from me 200,
35:10
000 to 3, 000 a month, my overhead is more, is about 300 to 500, 000 dollars. For a spine fusion, the Haskell will make350,
35:25
000, I make800. The craniotomy and the cares, I make800 that has
35:30
to make500, 000.
35:33
So the unemployed, the unemployed neurosurgeons are not getting re-embarrassed. Then I start to say, well, maybe I need a better billing and the coding company. If you get a good billing and
35:46
coding company, now they take 10 from me, 10.
35:50
And the 10 because they have to talk to the insurance to get approval for a micro-disconnect me that I'm gonna get re-embarrassed for200, 300
36:01
So this is how it is unsustainable. So now, my
36:09
people around me,
36:14
they said, Dr. Galli, why you continue to have this hobby of neurosurgery that you're spending all your money, you're probably gonna make a little money to enjoy if you don't practice neurosurgery,
36:24
if you close your practice. But this is really what it is And now here is the best part that you're gonna, I love. This is really the best bond they allow. Everybody said Obamacare. Everybody
36:37
said that is affordable care, right? Okay, perfect. Every patient called me. It's a, you don't want to deal unfortunately with these patients because all of them, everyone called me, have a
36:52
problem, either in disability, looking for drugs, or it's showing somebody and that said, okay Now, but here's the biggest, biggest, like, it's incredible that the media not surface. If I see
37:07
a patient, Dr. Ashman and Surrada, you're not going to believe this. And Eric, for established in Illinois, the Starbucks coffee, when I stand in the line, people in front of me pay30 to get
37:22
Starbucks coffee with one pastry. If I see a new patient, I will get30, But it is the problem. It is the problem. the Starbucks, that said, pay
37:37
the30, the coffees I would don't see your face any back. But here's what usually happened with me, is I get audited. I get a letter in the facts about 15 pages from the government to tell me,
37:51
you've been audited for that visit. So with that visit for30, one clinic visit, I did not do any damn procedure, I'm getting audited. For this audit, I talked to the guys, probably sounds like
38:06
a high school kid. And this is a, this is what they supposed to do and all this. So they wanted me to see what I, what, what I wrote in my graduation, this is my job.
38:18
So what is the summary, neurosurgery went downhill, they, I remember when I went to the double A and S, then maybe the double A and S is not going to like me, but this is a fact in WNS I remember.
38:32
15 years ago, they had a dinner. At that time, WNS said, and my organization said, we're gonna defend the neurosurgeons. We're gonna make sure the reimbursement. So there was a hot dinner every
38:46
year to have a dinner as well as with the dinner, you discuss how to do better billing, future and all of this. So the neurosurgeons that they actually appointed by the Dublinists to the Washington
39:03
DC, that they recruited them to tell them for each code, how much money the neurosurgeon deserves. And at that time, those neurosurgeons, kid you not, which are the academic, they are the ones
39:18
to sign to say that, Kraniatami, you take 800 dollar. For this is you take this, this is real story. So I talked to the guy, And he was in one of the board members, and a big guy in Dafel, and
39:31
yes, and I said. You keep telling me that neurosurgery are well-respected. We are fewer, only 2, 000 people in the United States were so important. And yet you're giving me an academy500. And
39:44
you think that this is good? How can you respect, how can you say that it's a respected field and you allowing this to happen? And this is really the story. The story now, when I do, I do
39:57
anesthesia to urologists to just name it It's just the, the grading to an orthopedic surgeon. I tell them, I'm a neurosurgeons here to make money to submit my neurosurgeon practice. I'm doing
40:11
anesthesia. Okay, anesthesia now, are not sure a brush brush than neurosurgery. My anesthesiologist will literally make3, 000. I will make300 to800. And he'll take a, We see the
40:30
patient five minutes before surgery. He'll he'll build per hour and at the end they have all this money for me I have I bring the patient I do everything for these patients and at the end of this
40:44
This is what usually happened is I am I am I'm getting nothing So why because they decided that only but only getting paid per procedure Not by the quality. No, but what to what you do and for how
40:59
long
41:01
I? Do you do you feel strongly about this?
41:07
No, no, it's it's really it's like it's like you're gonna say United States You're gonna hear you're gonna put up with Walmart. There is no private the private grocery stores You will gonna buy
41:22
from From let's say Macy's. This is what happened health care. You're only gonna put up with the coropress with the employed neurosurgeons that nobody knows their names and that's it. This is
41:36
really the real story that thinks the way it's going now. Let me ask you this. Hi, you've resisted the employment model. How do the other neurosurgeons in Chicago, do they have the same feelings
41:50
as you are? I have you, I have you. Okay. I have you. So the other neurosurgeons in Chicago, 'cause we missed your picture a little bit, the other neurosurgeons in Chicago, are they
42:01
intimidated into silence and accept this, what's happening? Okay, so this is an outstanding question, outstanding. Like, that's why we love Dr. Asma. He's just, you put him in any moderator,
42:15
oh my God, it's just the cool question. So I'm gonna, everything they tell you, Dr. Asma, and the team is actually what actually happened in life. It's real stories. So here is the sad part.
42:30
we lost too.
42:34
I think they went to, God forgive me, the stress, the unhappiness, the
42:44
poverty there end, the type of life, being told what to do, being harassed, for not following the protocol, all of this stuff. Many went to different, unhealthy, I don't want to say it habits
43:02
that ended their life. God forgive me to say that. So they died at the age of 56, 57. I lost about three old ladies, which is really hard to break English harassment. These people, when they
43:14
were unemployed, when we're unemployed, they were, oh my God, they were trained, one of them trained in Loyola. The guy was operated with, you'll never see somebody like him and the others.
43:29
They gradually, downgraded, harassed, intimidated, we call them in Egypt, buried alive. You bury them alive by keep hitting them and keep telling them what to do. They have to work for a
43:44
protocol. If you don't for a protocol, you get to the inside the oversight committee. You're going to be being reviewed. You're going to have an internal medicine to tell
44:01
them here is evidence-based practice is said that the mask is so important. Six feet out is important. And then few years later, you find that this is all bogus for instance. But this is what's
44:06
happening in neurosurgery. So we lost them and I do more get retired. So now I don't have this employee. This is the unemployed, respectful, neurosurgeons, hardworking, care about the patients
44:23
gradually vanished away. So who's there now is the employed And a lot of the husbands now are hiring the people that just graduated. So they're very happy. Why? And those happy, they're, why
44:37
they're happy. They're happy because they love the lifestyle. They love the shift. They call it now shift. Call shift. My shift is this. I'm not on call. I'm not, this is five o'clock, I'm
44:52
done. So in order for them to do that, or this is, there is no continuity And then when they present a case, Dr. Osman, this is how they presented. A patient called, I had some business with
45:04
an MRI. Here's the tumor. Let's review the slides. Here is the bus to operative MRI. So they became technicians. So what is the employed neurosurgeons now? There are a bunch of technicians. And
45:16
I know a lot of them will not like it. Do you know much about the history what the nurse practitioner is seeing? Are you gonna see the patient after surgery? No, the nurse practitioner is gonna
45:25
give me the appointment I'm gonna be in the operating room. So the things that we used to laugh, so I used to laugh as a pain management specialist as well, that the pain specialist would say, I
45:40
looked at my schedule last night and I have 30 procedures. I don't know what, I never met any one of them.
45:48
So here's come seven in the morning. He looks at the nurse practitioner. What are I supposed to do for this? Oh, you're gonna do it L3, 4, you do it with your L, okay. Let's do it. Next
45:58
That's it. This is really the coribrate. So what is the coribrate now is the technicians. We are slaves to the coribrate. Well, everybody agree with that, right? The next now level is coming
46:11
because you've been asking about what is the future. We're going to be the slave of the AI because now I'm going to tell the I the computer.
46:21
I'm going to tell it. Hey, John presented with this and this. Yeah, John John presented with this and this, but I'm not going to listen to John. I'm gonna let John talk to the computer and I bet
46:31
you this is what's gonna happen. I'm gonna talk to them because this is what we do now. John talk to the computer, what's bothering you? John will say this and
46:43
listen to this. The AI will review the films. The AI will review what they say. And he said, here's what he's supposed to do, Dr. Osman.
46:49
Okay, what's your, it's a very astounding statement that you made of what's going on I think
46:58
Eric, what's your, and Strata, which you heard Jay, and you heard Eric, you heard Strata, what do you guys think about all this? It looks like it's the same song, and sometimes played louder,
47:11
but it looks like underlying, it's the same song. What do you think, Eric? Yeah, I think we're hearing the same thing over and over. I think, you know, my problem with it is I think it's a
47:21
deeply broken system And, you know, I was speaking before. Ramses before you came on the line, I do think that, you know, there's the financials are a big deal because, you know, with the,
47:35
with the low reimbursements, we share that problem and not increasing overhead. You almost can't do it. You almost can't practice anymore. But there's that other aspect of it, which is the, the
47:46
fact that the quality is out the window. It's been taken out of our hands. And, you know, one thing that you almost touched on, but I think we just have to be upfront about is that I think
47:58
organized neurosurgery has completely let us down. Jim, you and I have talked about this and, you know, you go to the double AS meetings or the Congress meetings and they're, they're doing the
48:09
same thing. I mean, you're hearing a breakfast seminar or a lunch in seminar about how I do it, clipping basil or tippy aneurysms, which all, you know, nobody cares about at this point. I mean,
48:19
I personally do, but most people don't and, you know, these types of things, and nobody's really talking about the fundamental problem that on the ground, people, we're dying. And there is this
48:32
concept of shift work, which I mean, I'm going to retire and not practice neurosurgery anymore before it gets to that. You know, I operated on a patient with a complex tumor on Thursday, and now
48:45
it's Sunday. I don't turn off my pager. I'm available for that patient. In addition to the fact that there's probably nobody else covering at that hospital who's going to be able to deal with it.
48:55
If that patient has a problem because it was a complex cerebrovascular problem, even if it weren't, there's a bond between me as a neurosurgeon in that patient that I would expect if I were the
49:06
patient to be available to take care of them if they had a postoperative complication, and that's completely out the window. So I think we're hearing variations on a theme, some unique problems in
49:19
Nevada, problems in Illinois, I didn't get into some of the crazy stuff in Minnesota that we deal with provider tax, other like lunatic stuff and some of the problems. But it's really the same
49:32
issue, which is that organized neurosurgery has allowed our profession is collapsing around us and they're rearranging lectures on the Titanic. And unless there's a ground roots effort, like Jim,
49:46
what you're trying to do, and I mean, maybe we can do it, maybe we can influence something 10 years from now, I would be very, very scared to be a patient who needs neurosurgery in this country.
49:58
I mean, I think it's a disaster. I personally, I think it's a disaster. Maybe I'm exaggerate. Maybe I'm wrong. Maybe I'm overestimating. But are the good surgeons? Are the good neuro surgeons
50:10
who care about their patients in quality? Look, I mean, Astrad is not working right now, you know. I mean, Ramsi, I don't know how you're working with what you're describing. I mean, I'm -
50:21
What are we gonna do? Yeah, it's because we are the generation that went to neurosurgery for the real reason and we're not gonna give up. One thing also, Eric, is not just
50:40
the organized neurosurgery, it's the AMA that did all the evil as well for us The other thing is, I have to believe that America is still a good country. They chose Obama, Trump now, again, it's
50:53
all the odds to bring some sort of a change. I send the boss to Trump to tell him that if you wouldn't want healthcare to be great again, you need to get somebody like me or somebody like Dr. Usman
51:09
or Eric because the privatization, the, the, the, the, essential, beautiful healthcare that we don't want all to be walmart
51:23
of this country, or McDonald, and that's it. And I'm not putting this down, but you have to have different sectors. You cannot have one overall company, like a corporate, to do this. The
51:39
essential questions also, this is I always think with my Jewish head a little bit that there is somebody behind that that have
51:52
a vision. And here is the vision, Eric, that I'm going to tell you, and maybe this is what it is. And that vision is we're going to take the control of
52:04
people like me and you. And we're going to have the AI that handles patience. And I feel that this is what's happening because Five years from now, people, even my residents, are not as smart as
52:21
you and me. They have no retained knowledge. The computer, the Google, the evidence base, whatever it is, knows more than them. So is it really true that five years from now, they want the
52:35
technology to do the surgery, to work to operate in patients and to do all of that?
52:43
It's very alarming, very interesting answer. Yes, yes, yes, because I see it. You know, in the anesthesia now, Eric, I do anesthesia, and I used to be like, I feel respected neurosurgeon,
52:57
but when I do anesthesia, I see it,
53:01
the orthopedic or somebody say, I'm so sorry that you're doing this for me and my patients, I thought that neurosurgeon You guys make a lot of money and you don't need to do all the stuff, but then.
53:15
in the new version of the anesthesia ventilator, Dr. Asma, do you believe this? They start to have the buttons in the machine that you just push and say, I want 50 oxygen and 25 nitrous. And I
53:30
told them, I picked you, GE. The next version is going to be ab-in-the-phone. Gee, I'm just going to put the ab-in-the-phone. And you start to say, Deliver this anesthesia And I think this is
53:43
what we're going through now. You know what I mean? That is why there is a bush for the navigation, for the robot, for all of the stuff, because they want to do as much automated as you can. Do
53:54
you believe this? Do you believe that this can be the potential that we see? Yes, I do. Let me ask you, Strada, what's your take on all this? Because I've taken enough of your time. But what's
54:06
your thoughts about this? And then thoughts going forward?
54:11
I think is not a It's not just a neurosurgery problem. It's a health care problem. It's a health care, you know. Everything we're talking about is applicable well beyond neurosurgery.
54:25
I think - And your
54:28
wife is a, she's an intern, isn't she? Yeah, she trained her family medicine and then she trained in,
54:38
she's done a lot of training, integrated medicine and she lifestyle medicine, but she's not, with her practice that she's setting up your, she's not taking insurance. She doesn't want to deal
54:50
with it.
54:52
And it's because it's such a burdensome process. I think we took her - Don't cut to Minnesota, astronomy. If you won't take insurance, they're trying to start, they're going to try to take your
55:07
medical license away. Is that right? Wow, this is amazing. That's amazing.
55:13
I think
55:15
we see it, physicians seated control. I mean, I think that's what we did that a long time ago. I mean, just look, this old business of CPT coding, I mean, it's so artificial, but now we have
55:30
people who are tailoring what they do to fit into a CPT code that doesn't really capture what you do. The art of
55:42
a
55:44
physical examination is lost. I mean, patients that I see for another opinion, they weren't even examined by the previous precision. I see notes that are just copy and pasted notes and it's just
55:57
meaningless. And
56:01
quite honestly, Jim, I don't know what the answer is. I was willing to join in and have some discussion, It's a it's a huge problem. I mean, I think I think we need like minor physicians to come
56:16
together and think about what was the solution, but there has to be a fundamental change in how we do things in the healthcare system. I mean, I think it's much bigger than neurosurgery. One thing
56:28
that one thing that Dr. Aspen that a similar situation and they brought up during the debate, residential debates and all of that, that and I read it in many places, neurosurgery do not have
56:45
enough representation in Washington.
56:49
I think we have a very golden opportunity to go and have a meeting with Robert F. Kennedy with the health to explain to him about who we are and what we see because we all love this country And so he
57:07
is, and he's also thinking out of the box. We have also a president that whoever he selected, they think out of the box. There is no doubt, each one of them, but especially Robert F. Kennedy
57:21
and all of us. I think it's a golden opportunity from all of us, and you're really well connected, and I am willing, and I'm sure Strada's willing and Eric is willing to go to Washington. I think
57:34
we need to have our voice heard there, and then after that, we'll start there There is a lot of people in this country that they want you, they want me. If you look at my Facebook, all the
57:48
stories of my patients, and
57:51
they tell me how much they admire, and they tell me I'm one in a million for what I do. And so is Eric, and so is Strada, and so is you, the harassment, until today you're doing so much for us,
58:03
so, a neurosurgery. I'm gonna have to go, I'm gonna have to go with you. Go ahead, I think we're - I will say, I mean, I'll leave you with this idea, which is that I I think it's desperate and
58:15
I think it calls for desperate measures and I think we have to, I like what Ramsey said, I would go to Washington, I think we have to think out of the box and personally, I'm not sure you can
58:26
salvage this without rethinking the way neurosurgeons are reimbursed. The CPT coding, you know, the fact that they've been able to ratchet that down and pay the hospitals more is not working. I
58:39
mean, just the fact that we can only, we're tied into these insurance contracts. As I said, some states like Minnesota are going to try to not allow you to be out of network. It's very hard to do
58:51
here anyway anymore. But
58:55
what other profession is it where, you know, I can only collect based on this like ridiculous artificial RV you number for what I do. I mean, this is insane I mean, as you know, as you probably,
59:09
as I'm sure you guys know. I mean, look at the, the, the, the, the, the CPT code for, um, extracurricular, your cranial bypass, you know, the procedure that we, we spoke so much about and
59:20
how many RV uses that for that hard operation compared to a lumbar fusion or something. I can't charge what I want. I can't be paid what I deserve. It's extraordinarily demoralizing. And I mean,
59:33
this is going to require rethinking everything. If you're going to salvage the system, the way it ideally should be, the way we were trained and the way we, you know, the way patients deserve. I
59:44
don't know how else you do it. Well, there are a few references that may be helpful to you in this talk. Be ready to take some screenshots so you can save them for your records.
59:59
The first reference is by Anthony DeGiorgio on neurosurgical economics, perspective payments and market distortions.
1:00:10
It was published in the California Association of Neurologic Surgeons' newsletter, Volume 52, 2024. You can reach Emily at CAN, C-A-N-S-1org, and
1:00:25
you can obtain that information.
1:00:28
Second reference is by Conrad Black, a known columnist, who describes Canada's healthcare system, which is in desperate need of reform His article was published in the Epic Times, and the email
1:00:42
address is listed.
1:00:45
In a series of papers by the FLCC Alliance, an association of almost 20, 000 physicians,
1:00:55
publishing articles on COVID and healthcare and the healthcare system,
1:01:02
and the email, the website is given below
1:01:11
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