T he American College of Surgeons (ACS) Board of Governors’ Committee on Socioeconomic Issues has been very busy this past year.
Surgeons as employees
The committee’s activities have centered largely on the development of a white paper addressing the roles and future of surgeons as employees. The committee believes this is an important issue in light of the fact that a large number of graduating residents as well as established surgeons are now negotiating contracts with large multispecialty groups, health systems, or hospitals.
The committee determined that the white paper should address a broad number of issues that these surgeons may face and should consider when deciding whether to sign contracts as well as other matters of concern related to employed surgeons. These considerations include the following:
- What is the vision and mission of the institution?
- What are its values?
- What role will physicians play in leadership?
- What is the clinical service model in which they may be engaged?
- What are the patients’ needs?
- How is the physician to remain an effective patient advocate?
- What are the strategies for meeting financial requirements?
- Are physicians valued beyond their role as simply providers of clinical care?
The committee’s white paper will also address complex and multilayered questions and topics related to the subject of surgeons as employees, including the following:
- Will physician compensation be set at market rates?
- Will related centers be aligned within the system’s goals?
- Will physicians work in clinical teams with other physicians for the benefit of patient care and services?
- Will physicians collaborate, develop, and accept the policies for best practices and evidence-based clinical managerial outcomes?
- Will physicians be held accountable to peers and the system for their professional behavior and abide by organizational values or an approved code of conduct?
- Will physicians operate with a common employment agreement in terms of distances and of individuals’ clinical specialties?
- Will physician clinical practice be governed by credentialed privileging criteria policies and procedures as developed by other physicians in the systems?
These are just some of the questions that will be addressed in this white paper, which the committee believes will be of value to Fellows and other members of the College as health care continues to evolve and change.
Health care reform
In addition to the white paper on employed surgeons, the Committee on Socioeconomic Issues has continued to focus on the topics that relate to the overall ability of surgeons to maintain their practices and provide quality patient care. In particular, the committee continues to be concerned about the requirements in and implementation of the Affordable Care Act (ACA). These concerns very much relate to physician reimbursement and bundled payments for procedural-based care. The committee understands the need as well as the overall desire to reduce costs in health care, efforts which most physicians support.
However, the committee believes the provisions in the ACA will put a number of physicians at risk for reduced compensation and, thereby, will add to the significant shortage of physicians.
The white paper is relevant to the College’s ability to address these issues as well, because many of these factors will drive consolidation of health systems, create incentives for physicians to be employed, and will drive private physician groups into near extinction—particularly due to the cost of adopting electronic health records, which are central to many of the ACA’s provisions.
Furthermore, the ACA seeks to move patients into integrated health systems known as accountable care organizations (ACOs). The committee is concerned that ACOs will become not only medical homes for patients, but will be at the forefront of reducing the total cost of care. In this role, it is likely that ACOs will often see surgeons not as producers of quality outcomes, case volume, or revenue, but as cost centers. This situation is likely to arise if primary care physicians are perceived as gatekeepers while surgeons become viewed as the providers who drive up costs.
These issues are of significant concern to the members of the committee and, we believe, reflect in many ways the concerns of the constituents of the College and its Fellows. The committee believes it is critically important that the College educate Congress about the value of surgeons in delivering health care and the significant and real shortage of general surgeons, especially in rural areas—a problem that is likely to increase as Baby Boomers retire and physicians become more aligned with health systems in major metropolitan areas.
The committee also focused—as it has over the last several years—on medical missions. These missions have become an increasing important part of life for academic, employed, and private practice physicians. Medical missions provide an opportunity for physicians to give back in areas of significant need, not only in this country but more often abroad in developing countries, which benefit very much from skilled physicians who are willing to give of their time, energy, and effort to train health care professionals and treat patients who are in desperate need of surgical expertise.
This year’s Volunteerism Award recipients continued to reflect the outstanding contribution by surgeons and the overall growth of interest in this field. The committee had numerous applicants for each of the outreach positions, and after a thorough review process the committee selected two winners who will be honored at the 2012 Clinical Congress. The committee believes medical missions will continue to be a growing trend for many members of the College who, informally and formally, provide services abroad. Today, many trainees in surgical programs are exposed to this setting, which may lead to the development of a pipeline of surgeons committed to serving in medical missions. The interest in medical missions continually drives home awareness of both the fortune and opportunities that we still have in America to practice as surgeons and the compelling need that we see abroad for many of our surgeons to take the lead in caring for others.
Quality and outcomes
Issues related to quality and outcomes in care continue to be a priority for the committee. Joseph Tepas, MD, FACS, Vice-Chair of the Committee on Socioeconomic Issues, has led the initiative to further define the quality of care and to encourage physicians to establish quality care guidelines and initiatives in their own hospitals and in their region. It is clear that many efforts to improve outcomes in health care will be geared toward improving quality in procedural-based medicine. This probability means that surgeons have a real chance to be engaged in a collaborative effort with their hospitals and their health systems to implement quality metrics, which, with or without our input, will often be used to determine pay and reimbursement, and to measure the overall performance of a physician group or a hospital. We believe that engagement in these efforts will best serve our patients and our profession in the future.