Most surgeons seek to directly assist our patients through the course of their illnesses, paying little attention to the political environment or health care policy. After all, arguably, among all specialties in medicine, surgery can demonstrate the clearest relationship between clinical action and patient outcomes. However, over the last decade, it has become increasingly apparent that the independent patient-surgeon relationship is slowly vanishing.
Surgeons as political advocates
When we’re sitting with our patients in the clinic, rounding by the bedside, or operating in the middle of the night, worries regarding insurance coverage, Medicare reimbursement, and litigation may find their way into the physician’s conscious and/or subconscious thoughts. The fact of the matter is that the provision of health care services has grown in the last century from a two-person contract to a complex relationship that involves multiple stakeholders. It was only a matter of time until health care policy started to be shaped mostly by non-clinicians.
The rising health care costs and the variability of patient outcomes across different providers has led to the development of multiple performance indicators, as an attempt to improve quality of care while decreasing costs. The Centers for Medicare & Medicaid Services and private insurers immediately adopted many of these indicators for pay-for-performance purposes, despite multiple clinical studies suggesting that some of these measures were unreliable.1 The surgical profession’s failure to make itself heard in this specific instance and in many similar situations is due in part to our unfamiliarity with how policy is shaped and with the political process. In other words, our traditional focus on academia rather than advocacy has not served surgery well in recent years.
Over the last few years, the American College of Surgeons (ACS) has increasingly recognized and improved upon its ability to advocate on behalf of all surgeons in the U.S. The ACS established the American College of Surgeons Professional Association (ACSPA), which, because of its tax status, was able to form a political action committee (PAC), the ACSPA-SurgeonsPAC, with the goal of relaying the perspective of surgeons to members of Congress.2 In the current era of health care reform, it is becoming more and more essential that we make every effort to be influential players in health care policymaking; otherwise, politicians and bureaucrats with little or no understanding of patient care will decide for us.
What is political advocacy?
Advocacy is part of the political process, and is defined as the actions of an individual or a group engaged in an effort to influence public policy through political, social, and economic systems and institutions.3 Advocacy covers a broad range of activities, including public speaking, media campaigns, research, and lobbying.3 In fact, lobbying is a key part of modern politics. It is defined as the act of approaching legislators directly on an issue in attempt to influence his or her decisions.3 Anyone can lobby, including individuals, groups, constituents, private-sector interests, corporations, government officials, and, of course, advocacy groups.
Quite often the act of lobbying has negative connotations associated with it, as some individuals may interpret this process as involving people with significant socioeconomic standing who use their power, money, and influence to corrupt the law and for personal gain. However, lobbying can be a tool that is used to protect others’ interests against corruption, ensuring that minority interests are fairly defended. In general terms, the value of lobbying and advocacy comes down to who is best able to convince their legislators to see things and act upon them from their point of view. One key access point that lobbyists have to legislators is through campaign contributions.
In 2010, the Center for Responsive Politics estimated that candidates in the 2010 midterm congressional election spent approximately $3.7 billion.4 To finance their campaigns, the candidates relied on assistance from a variety of sources, including individuals, interest groups, corporations, and unions. For federal elections, the primary source of campaign funds is individuals, followed by PACs.
PACs are organized for the purpose of raising and spending money to elect candidates who are likely to uphold the beliefs or interests of their members. PACs raise money from their eligible membership, and then make contributions to political campaigns. These groups also encourage members to become more politically active by providing relevant educational materials, organizing meetings, and facilitating congressional visits between legislators and PAC members.
Political money in our system is divided into two categories, “hard dollars” and “soft dollars.” Hard dollars are contributed by an individual and given directly to a candidate, political party, or PAC. These dollars are reported to the U.S. Federal Election Commission, which regulates campaign finance and enforces strict rules on who can contribute to candidates and to what extent. Contributions are capped at $5,000 per PAC per year.5
Soft dollars are contributions from either corporate accounts or dollars spent by unions and are used for administrative and educational purposes. Recently, due to the U.S. Supreme Court’s decision in Citizens United v. Federal Election Commission, soft dollars have been allowed to be used for election-related independent expenditures. Regardless of the type of contribution one makes, be it in hard or soft dollars, it is important and vital for everyone to be an active member in their respective PACs, and contributing is a good way to start.
So, suffice it to say, advocacy is important for the future of your career. The next step in becoming a surgeon advocate is figuring out how to participate in these efforts despite a busy and demanding schedule. In reality, meaningful advocacy work can take place fairly quickly in the form of a phone call, a letter, or an e-mail—and we all have time to make one more phone call or send one more e-mail.
The first step in getting involved is to understand the issues. Although this is another task that may seem daunting or time-consuming, many resources are available to help surgeons get up to speed on relevant issues. Many different websites, blogs, and listservs are available to physicians seeking to stay current on legislative activities. Advocacy experts suggest the best way to become a more influential advocate is to focus your attention on topics about which you are most passionate, and then seek out information regarding legislation on that specific topic. Registries of active legislation organized by topic exist on the U.S. Senate and House of Representatives’ websites. Alternatively, to narrow a search to health care-related topics, the ACS Division of Advocacy and Health Policy has a very detailed website that summarizes state and federal legislation on which the ACS has issued statements.6
The five-minute phone call
Five minutes may not seem like enough time to make a substantial impact, but every phone call or e-mail represents one more of that representative’s constituents. It is not always possible to speak directly to a representative, which is fine as long as you are talking to someone from the representative’s staff. The staff members collect these opinions, tally the counts, and summarize the findings to the legislator. And there is power in numbers, which means it is important to encourage colleagues to participate in grassroots efforts as well. Website references in the box on page 15 provide guidelines for locating and contacting representatives by phone, letter, e-mail, or even via social networking tools, such as Twitter.
With regard to key topics, such as sustainable growth rate (SGR) repeal or health care reform, specialty groups, including the ACS, draft talking points to which users may refer during phone calls or when writing letters and e-mails to policymakers. However, these talking points are only examples or templates of items that may be covered during these exchanges. The important thing to remember is to speak up about what is important to you, including topics outside the realm of health care. The key purpose of these communications is to build a relationship with a representative. The more times you call, the more you move from “just another caller” to “a concerned and engaged constituent,” which will only strengthen your ability to discuss pertinent issues with your representatives, and influence their perspectives on issues that are important to you and your profession.
Select federal and state issues relevant to surgeons
|SGR||Each legislative cycle, the SGR, which is a flawed formula used to calculate Medicare reimbursement, is perpetuated by the U.S. Congress, creating billions to trillions of dollars in potential debt that ultimately may result in sharp Medicare payment cuts to physicians, particularly surgeons.|
|Tort reform||Medical liability insurance rates continue to rise and make provision of care in certain locales unattractive or financially impossible. Tort reform offers the promise of limiting liability and may help preserve the viability of surgical practices.|
|Workforce issues||Recent threats have included proposed cuts in graduate medical education funding, which would limit the number of residency slots and worsen the surgical workforce shortage.|
|Trauma systems funding||The trauma system provides care to millions of Americans each year, and additionally provides provisional support in the event of mass casualty scenarios. Funding continues the support of the maintenance and improvement of this critical national safety program.|
|Scope of practice||Each year, nonphysicians push for titles and privileges previously restricted to physicians and surgeons. This threatens both practice viability as well as public trust in the health care system as non-qualified individuals are permitted to prescribe medications or perform procedures without adequate training.|
|Biomedical research||Research is the foundation of discoveries that change the way we practice. As budget cuts threaten research funding, the surgical perspective on critical biomedical issues and the importance of funding research efforts is vital.|
Many state and professional medical societies host advocacy days at the local or national level, such as the College’s Advocacy Summit. These organized events usually start with a morning overview of the issues and talking points, followed by meetings with lawmakers. Visits with elected officials or their staff members can occur at any time throughout the year.
Another way to get involved is to join a PAC. The strength and ability of a PAC to communicate messages to legislators comes from members’ donations and participation. There is an old quote, “You either are at the table or on the menu,” and supporting PACs ensures that they stay relevant and important and continue to be key components in successful political lobbying and advocacy.
The price of apathy
Fortunately, a nation governed by democratic rule affords its citizens the opportunity to engage in political activities to whatever extent they wish. However, U.S. physicians and surgeons have often been reluctant or relatively unwilling to participate in the political process. Physicians, on the whole, voted in federal elections at lower rates than the general population, and traditionally have had limited involvement in political activities.7,8 The reasons for this apparent apathy are many and are as individual as each physician’s personal beliefs and professional practices. Nonetheless, the simple truth is that a collective lack of participation by physicians and surgeons will ultimately place decision-making power into the hands of others whose understanding of the day-to-day practice of medicine is limited, and whose comprehension of the health care delivery system lacks appropriate perspective. As a consequence, policies may emerge that are often irresponsive to the needs of physicians or patients.
The cost of indifference has the potential to be very high for surgeons. With the passage of the Affordable Care Act (ACA) in 2010, we have been launched into one of the most pivotal times in the history of U.S. medicine.9,10 The ACA will have far-reaching implications on nationwide health care delivery and finance and will affect the practice of surgery and the lives of surgeons in ways that are likely not entirely known at this stage of planning and implementation. Continuing to evaluate the feasibility and impact of the ACA as it transitions from paper to practice will require a concerted effort and strong leadership from the surgical community. Aside from the monumental shifts resulting from the ACA, several issues relevant to surgeons are currently being addressed in Washington, DC, and in state capitals nationwide, and those merit attention as well (see table).
Apathy toward these issues may or may not ultimately lead to unwanted consequences for surgeons and their patients. To use a pertinent example, consider the issue of the SGR. The SGR was developed and implemented to allow for increases in Medicare physician reimbursement based on the volume and intensity of services delivered, but was also designed to limit increases in the Medicare budget by implementing fee reductions for services that exceed spending targets.11 Unfortunately, flaws in the SGR have led to discrepancies between budgeted funds and payments, and with each passing fiscal year, the cuts in physician reimbursement are added to those of the previous year. This policy has not yet led to a significant decrease in physician reimbursement because Congress has consistently provided temporizing “fixes” to maintain reimbursement rates. These temporary patches have had a cumulative effect, and physicians now face a potential Medicare payment cut of nearly 30 percent in 2013. The consequences of this situation are potentially devastating to surgeons, as cuts of this magnitude threaten the ability of practices with large proportions of Medicare patients to remain financially viable. It further has the potential to lead to declining surgeon participation in the Medicare program, leaving a significant segment of society without access to appropriate care. The impact may be more far-reaching than this, though, because many private insurance companies base their reimbursement rates on what Medicare pays, leading to a second hit to surgeons, regardless of Medicare participation. This would be a doomsday situation for the U.S. surgical community.
Surgeon involvement in advocacy offers no guarantee that scenarios such as the one previously described can be avoided. However, without large-scale participation by the surgical community, the opportunity to help shape reasonable solutions to these types of challenges will be lost.
The world of health care is changing rapidly. Surgeons can no longer sit in their offices or focus solely on work in the operating room when it comes to taking care of and watching out for their patients. The political world has continued to merge with the health care world, and it is the surgeons’ responsibility to ensure that their patients have access to the best care possible. Being politically aware and politically active has now become a core part of being a practicing surgeon. The more surgeons are involved, the better things will be for our patients and for the world of health care. We are already leaders in the operating room and in the hospital; now we need to take the next step and lead outside the hospital walls as well. Our patients do not deserve anything less than that.
How to find and contact Congress members
- Kaafarani HM, Borzecki AM, Itani KM, Loveland S, Mull HJ, Hickson K, Macdonald S, Shin M, Rosen AK. Validity of selected patient safety indicators: Opportunities and concerns. J Am Coll Surg. 2011;212(6):924-934.
- American College of Surgeons Professional Assocation-SurgeonsPAC. Available at: http://www.surgeonspac.org.
- NP Action. Lobbying versus advocacy: Legal definitions. Available at: http://www.npaction.org/article/articleview/76/1/248. Accessed May 24, 2012.
- The Center for Responsive Politics. Midterm elections will cost at least $3.7 billion, Center for Responsive Politics estimates. Available at: http://www.opensecrets.org/news/2010/02/midterm-elections-will-cost-at.html. Accessed June 13, 2012.
- The Federal Election Commission. The FEC and the federal campaign finance law. Available at: http://www.fec.gov/pages/brochures/fecfeca.shtml#Contribution_Limits. Accessed June 13, 2012.
- American College of Surgeons. Division of Advocacy and Health Policy. Take action: Protect your patients and your profession. Available at: http://www.facs.org/ahp/index.html. Accessed May 24, 2012.
- Grande D, Asch DA, Armstrong K. Do doctors vote? J Gen Intern Med. 2007;22(5):585-589.
- Huddle TS. Perspective: Medical professionalism and medical education should not involve commitments to political advocacy. Acad Med. 2011;86(3):378-383.
- The Patient Protection and Affordable Care Act 2010. Available at: http://democrats.senate.gov/pdfs/reform/patient-protection-affordable-care-act-as-passed.pdf. Accessed February 28, 2012.
- U.S. Federal Election Commission. Quick answers to general questions. How much can I contribute? Available at: http://fec.gov/ans/answers_general.shtml#How_much_can_I_contibute. Accessed May 24, 2012.
- Dorman T. Unsustainable growth rate: Physician perspective. Crit Care Med. 2006;34(3 Suppl):S78-81.