The argument can be made that all elections are important. Certainly the election of 2012 is no exception. As health care expenditures continue to rise, Washington continues to focus on managing public and private spending while ensuring the delivery of high-quality medical care. With these priorities in mind, we, as surgeons and as patient advocates, should bear in mind the numerous legislative issues currently or soon to be the subject of debate. When we go to the polls to cast our vote, it is imperative that we consider which candidates have demonstrated favorable positions on issues of critical importance to surgeons and the patients to whom they provide care.
By vetting a candidate’s voting record and their current position with regard to the issues listed in this article, and then basing the vote on those issues, one could partially remove the personality, party, partisanship, and polarization from the voting equation.
Collectively, 78,000 members of the American College of Surgeons (ACS) have a much louder voice than they do individually. By voting on the issues from the surgeon’s perspective, you fulfill not only a civic duty but also the responsibility you have to your patients to ensure that they have access to the best-quality surgical care. Furthermore, taking the time to educate colleagues and patients on those issues that impact them directly, and encouraging them to similarly vet candidates with regard to their record and positions, magnifies surgery’s influence exponentially.
Repeal and replace the SGR
Nearly all stakeholders, including members of Congress, payors, and the medical and surgical community, agree that the Medicare physician reimbursement system is flawed. The continued volatility and uncertainty of the current system poses a threat to Medicare beneficiaries’ access to surgical care. As was the case on numerous occasions in recent years, Congress postponed the scheduled 29.5 percent cut in the Medicare physician payment rate—as calculated by the sustainable growth rate formula (SGR)—that was scheduled to take effect January 1. However, that action, or inaction, guarantees that the status of these cuts will thus be part of the legislative agenda during the “lame duck” session of Congress following the November elections.
Survey data have previously shown that if these cuts ever are put into effect, surgeons would likely make significant changes relative to Medicare participation.1 Over the past decade, surgeons have repeatedly advocated for elimination of the short-term patches, repeal of the SGR, and replacement with a payment system that provides stability in Medicare payment, preserves the patient-surgeon relationship, and ensures patients have access to the surgeon of their choice. Eliminating the SGR is critical to the establishment of a payment system that improves care, lowers costs, and better integrates delivery of care.
Currently, the unpaid debt on the SGR generated by the numerous temporary patches and postponement of scheduled cuts is approaching $300 billion.2 Before the most recent patch was enacted in December of 2011, a proposal to retire that debt through use of the Overseas Contingency Operation funds (OCO) was offered in Congress. Though some seemingly serious bipartisan discussions about such a solution for this debt took place in the Senate, the plan had little support in the House. It is anticipated that such a proposal will again be part of the discussion during the lame-duck session in November and December. Few would argue against using these funds to pay down this debt. No doubt, however, many other proposed uses for these funds and competing interests have and will continue to emerge.
Surgeons should consider a candidate’s position on both the repeal and replacement of SGR and the use of funds from OCO when making their decision for whom to vote.
Quality improvement initiatives
Surgeons understand that everyone, especially patients, benefits from collecting and analyzing physician quality data. Accordingly, it is important that the public receive accurate information on provider performance. In collaboration with their specialty societies, physicians are the most appropriate authorities to define and establish what constitutes quality care. This effort should include the use of reliable risk-adjusted outcomes and clinical effectiveness data, as well as the development of a reimbursement system that actually rewards physicians for improved outcomes.
Surgeons have been pioneers in the development of physician-led quality improvement initiatives, including several nationally recognized clinical registries that have been shown to improve outcomes and lower costs, including the ACS National Surgical Quality Improvement Program (ACS NSQIP®). However, the development of, and participation in, a registry can be expensive, and thus smaller practices and institutions may need financial support in order to participate. Incentives for participation in physician-driven quality initiatives are essential to support the implementation of this valuable tool in improving patient safety and in the provision of quality care.
The College is committed to improving outcomes and lowering costs through the expansion of ACS NSQIP. The ACS is working with members of Congress and congressional staff with the goal of attaining support for the growth of such programs and securing appropriate resources and incentives for their implementation.
Medical liability reform
Medical liability reform continues to be a priority for the College and its members. For more than a decade, liability insurance premiums have increased dramatically. Most surgeons see their premiums increase in spite of having never been named as a defendant in a tort action. In recent years, some surgeons have found it difficult to obtain liability insurance. When they can, the cost is often prohibitively high. Although there have been some successes at the state level, several state laws have been nullified by the courts or diluted so greatly as to be of only limited effectiveness. Accordingly, surgeons have been migrating to states where meaningful reforms are in place or simply have chosen to retire early. As a consequence, further reductions in the surgical workforce occur, particularly in states that do not have caps on noneconomic damages.
The College continues to advocate for the adoption of meaningful medical liability reform modeled after California’s 1975 Medical Injury Compensation Reform Act (MICRA). In the 37 years since its passage, data indicate that it is possible to stabilize medical liability costs while, at the same time, protecting patients’ rights. As an example, consider a comparison of premiums for general surgeons in California and New Jersey in 2009. Annual premiums in California averaged $41,775, whereas in New Jersey, a state that has no cap, they averaged $74,985.3
The College supports the following policies for addressing the crisis in medical liability and urges Fellows to vet and consider a candidate’s position on these policies when casting their vote in this year’s election:
- Reasonable caps on noneconomic damages
- Protections for physicians who provide care mandated under the Emergency Medical Treatment and Active Labor Act (EMTALA)
- Protections for physicians who provide volunteer services in disaster or emergency situations
- Alternative dispute resolution, such as the establishment of health courts
- Limits on plaintiff attorneys’ contingency fees
- Application of punitive damages only in cases in which there is clear and convincing evidence the defendant intended to injure or cause harm
The U.S. population is both increasing and aging. At the same time, the number of surgeons in active practice and available to care for surgical patients is decreasing. According to an Association of American Medical Colleges study, a shortage of 46,000 surgeons and other medical specialists will occur in the next decade.4 With this crisis looming, the College is concerned about policymakers’ current emphasis on primary care. Although primary care specialties are obviously critical to the delivery of health care, primary care services can be provided by a variety of health care professionals. In contrast, surgeons are uniquely qualified to provide a variety of lifesaving procedures.
Surgeons should endeavor to elect members of Congress who are committed to ensuring that patients will continue to have access to quality surgical care. Lawmakers can help to sustain the surgical workforce by supporting policies that protect funding for graduate medical education and that meaningfully address the shortages in the surgical workforce.
Trauma and emergency care
Surgeons recognize trauma as the leading cause of death among children and adults under the age of 44, taking the lives of more Americans than AIDS and stroke combined.5 Accordingly, it is crucial that patients with severe and complex injuries are transported to designated trauma centers. Trauma centers, with their dedicated resources, including specially trained physicians and nurses, provide the best possible chance for these patients’ survival. Indeed, seriously injured trauma victims have a 25 percent lower risk of death if they are treated in a trauma center rather than at an institution without specific trauma capabilities.5 Nonetheless, a report from the Centers for Disease Control and Prevention indicates that approximately 45 million Americans lack access to a Level I or Level II trauma center within one hour of being injured.6
Beyond the enormous effort needed to ensure the availability of trauma care across the country, an equally daunting challenge is emergency care in general. In its 2006 landmark report titled Future of Emergency Care in the United States Health System, the Institute of Medicine reported that hospital emergency departments are severely burdened and overcrowded and that emergency care is highly fractured. Due to higher medical liability exposure and the lack of adequate reimbursement for care provided, critical surgical specialists are often unavailable to provide emergency and trauma care. To alleviate this problem, the report called for a complete overhaul of emergency and trauma care by creating a coordinated and regionalized system modeled after the Trauma-EMS (emergency medical services) program. The goal would thus be to “improve patient outcomes by directing patients to facilities with optimal capabilities.”7
Because trauma is the second most costly medical condition in the U.S., the College firmly believes that improved access to trauma and emergency care for all Americans represents a prudent investment that will yield exponential returns in efficiencies, economies of scale, as well as public health and safety. Finally, because the public assumes that when they or their loved ones become seriously ill or critically injured lifesaving emergency or trauma care will be available, the College urges Fellows to support candidates who have a record of supporting policies aimed at ensuring the availability of a system of coordinated emergency and trauma care.
Education and action
Surgeons who are interested in learning more about the candidates’ positions on the issues outlined in this article have a number of options. Many surgeons, no doubt, have relationships with the candidates for office in their state and district and may very well have the opportunity through direct contact to determine their candidates’ views. Another option to consider is attending a campaign event where the opportunity to question the candidate in public forum is often provided. Finally, the staff of the College’s Washington Office is the source of a wealth of information on these topics and is available to assist Fellows in obtaining information on how supportive candidates have been in the past or might be expected to be in the future.
As citizens, it is part of our civic duty to actively participate in the election process by casting our votes. By becoming educated on a candidate’s position on issues cogent to the ability to provide quality surgical care to patients, surgeons are encouraged to consider the convictions of their profession as they go to the polls. In this way, surgeons will not only demonstrate responsible citizenship but also serve as responsible stewards of their profession and the patients for whom they daily endeavor to provide quality surgical care.
- Surgical Coalition. Report on the future of Medicare physician payment and the effect on surgeons and their patients. March 2011. Available at: http://www.facs.org/news/medicare032610.pdf. Accessed August 13, 2012.
- Hahn J, Mulvey J. Medicare Physician Payment Updates and the Sustainable Growth Rate (SGR) System. Washington, DC: Congressional Research Service; 2011.
- Health Coalition on Liability and Access. HCLA Medical Liability Reform Briefing Book. May 2011. Available at: http://www.hcla.org/sites/default/files/HCLA_BriefBook_CD_finalREV.pdf. Accessed March 2012.
- Association of American Medical Colleges. Physician shortages to worsen without increases in residency training. Available at: https://www.aamc.org/download/286592/data/physicianshortage.pdf. Accessed March 2012. Accessed August 13, 2012.
- Centers for Disease Control and Prevention. Access to trauma centers in the United States. Available at: http://www.cdc.gov/Traumacare/pdfs/TraumaCentersFactsheet20090921-a.pdf. Accessed March 1, 2012.
- Mackenzie EJ, Rivara FP, Jurkovich GJ, Nathens AB, Frey KP, Egleston BL, Salkever DS, Weir S, Scharfstein DO. The national study on costs and outcomes of trauma. J Trauma. 2007;63(12) S54-67.
- Institute of Medicine Committee on the Future of Emergency Care in the U.S. Health Care System. Hospital-Based Emergency Care: At the Breaking Point. Washington, DC: National Academy Press; 2006.