Anyone picking up a newspaper or watching a newscast these days no doubt reads and hears various aspersions cast upon Washington, DC, and its political denizens. Yes, Congress is back in session, and the town that is given to cliché appears to have picked up where it left off before the 2012 elections, with partisan bickering.
The only difference between death and taxes is that death doesn’t get worse every time Congress meets.
—Will Rogers, entertainer/actor/philosopher
Yet, there is serious business that must be conducted as numerous challenges face surgeons and surgical patients. The American College of Surgeons (ACS) is focused on advancing its health policy agenda amid the political minefield. This article is a prognostication of where the College’s primary agenda items are headed during the 113th Congress.
Prediction is very difficult, especially if it’s about the future.
—Niels Bohr, Danish physicist and philosopher
There are two distinct parts to the physician payment issue—present-day cuts to the Medicare physician payment rate and the future overhaul of the health delivery and payment system. At press time, sequestration went into effect and cut the Medicare physician payment rate by 2 percent with the nearly 30 percent sustainable growth rate (SGR) cut looming at the end of the year. The ACS acknowledges the need to reduce the nation’s deficit, but the sequestration cuts carry some potential ramifications. Some members of the College, as well as various policymakers, may argue that 2 percent will not have a significant impact on surgery; however, it opens the door to future cuts as the national fiscal debate continues. The ACS believes the new payment and delivery system will produce significant savings in the Medicare budget, averting the need for explicit cuts to physician payment rates. Therefore, the College continues to oppose any cuts until a new delivery and payment system is in place.
Although Congress may appear divided in general, most lawmakers agree that the nation’s health care delivery and payment system must be overhauled in the near future. Both parties agree that the Medicare program must move toward a value-based payment model and away from the current fee-for-service, volume-based model.
In late February, the ACS responded to a joint proposal from the U.S. House Committee on Ways and Means and the House Committee on Energy and Commerce requesting input on how to redesign the delivery and payment system, including the permanent repeal of the SGR. The ACS asserts that any new payment system should be based on the complementary objectives of improving outcomes, quality, safety, and efficiency while simultaneously reducing growth in health care spending. In order for any alternative payment system to be successful, the ACS and other organizations believe it should meet the following objectives:
- Ensure that quality and safety are the highest priorities
- Require that specific quality metrics are achieved before any savings can be shared among payors or providers
- Maintain the primacy of physician leadership within a highly qualified team of health care professionals working with patients to determine evidence-based courses of clinical care
- Acknowledge that surgical care is delivered in a variety of geographic locations and facilities
- Allow for innovative responses that may be required to address patient needs in urgent or unique situations
- Preserve the ability of a surgeon to recommend the surgical treatment plan that best meets the patient’s needs as guided by best practices and evidence-based medicine
The future of the delivery and payment system remains unknown, except that changes are forthcoming in both the public and private sectors. The ACS believes in the objectives described earlier in this article and advocates on surgeons’ behalf to ensure the new system strikes a balance between fiscal prudence, delivery of high-quality care, and preservation of the trusted physician-patient relationship.
Medical liability reform
To do the same thing over and over again is not only boredom; it is to be controlled by rather than to control what you do.
—Heraclitus, Greek philosopher
Medical liability reform continues to be a significant priority for the ACS and its members. For more than a decade, the College advocated for the federal adoption of health care liability reforms like those enacted in California under the Medical Injury Compensation Reform Act (MICRA) of 1975, including reasonable caps on noneconomic damages, limits on plaintiff attorney contingency fees, and application of punitive damages only when there is clear and convincing evidence that the defendant intended to injure the claimant.
The current congressional makeup—and that of the foreseeable future—hinders the ability to advocate on this platform. With valuable lessons learned at its October 2012 Medical Liability Reform Summit (see the March 2013 issue of the Bulletin for a complete overview [volume 98, no. 3]), the ACS is proactively working with other national physician organizations to seek alternative solutions at the federal and state level, while continuing to support its longstanding position on MICRA-like reforms.
The life so short, the craft so long to learn.
—Hippocrates, Greek physician
The viability of the surgical workforce and the ability to train future generations of surgeons remains a top concern for the ACS. A growing body of evidence points to an ongoing and increasing shortage of surgeons available to serve the nation’s aging and growing population. According to the Association of American Medical College’s Center for Workforce Studies, the U.S. will face a shortage of 46,000 surgeons and medical specialists in the next decade—a startling and troubling statistic for both surgeons and patients. Even the most ambitious plan would have only a modest effect in slowing the decline in the overall number of practicing surgeons over the next 15 years. These shortages will be felt most acutely in rural areas, where maldistribution has already left 1,144 counties with no general surgeons and nearly 900 counties without any practicing surgeons of any specialty. In addition, graduate medical education (GME), as well as indirect medical education funding, is a constant target for cuts as the nation deals with significant fiscal issues.*
Last year, a bipartisan group of senators requested that the Institute of Medicine (IOM) study the governance and financing of the GME program. Several proposals for addressing the shortage in general surgeons have been put forth, including a plan to increase the size of accredited surgery residencies along with a commitment to general surgery in residency selection criteria, increasing the flexibility and breadth in general surgery training, enhancing links with community-based hospitals, and seeking loan forgiveness opportunities for general surgeons. These recommendations could have a significant effect in addressing projected shortages. In December 2012, ACS Executive Director David B. Hoyt, MD, FACS presented the College’s views on physician training before the IOM. That meeting gathered perspectives from trainees, medical schools, researchers, medical societies, and other stakeholders. Dr. Hoyt spoke about shortages and the maldistribution of surgeons, as well as the effects of the 80-hour workweek on the readiness of surgeons emerging from training to enter practice, among other topics.
The ACS will remain a leading voice in addressing the critical shortages facing the surgical workforce.
A strong trauma system
The mission of the COT is to develop and implement meaningful programs for trauma care in local, regional, national, and international arenas. These meaningful programs must include education, professional development, standards of care, assessment of outcome, and financial accountability.
—ACS Committee on Trauma (COT) mission statement
The ACS and its coalition partners continue to advocate for trauma system funding to share information and disaster preparedness. Although many states have made great strides in developing effective trauma care systems, significant gaps in the nation’s trauma and emergency care delivery systems still exist. In addition, policymakers and organizations concerned about the state of trauma and emergency care must examine the details of those gaps and indicate how our current health care delivery systems would handle the surge capacity associated with a public health emergency or mass casualty event.
Last year, the Chairman of the House Energy and Commerce Committee, Rep. Fred Upton (R-MI), submitted a letter to the Government Accounting Office (GAO) requesting an assessment of the nation’s current trauma and emergency medical services programs. The GAO anticipates that the report will be completed by this summer.
The ACS will strongly advocate for the advancement of the organization’s policy objectives on the issues highlighted in this article and many others. Throughout the 113th Congress, College Advocacy and Health Policy staff will be reaching out to you to partner with us in achieving positive results regarding these issues.
*Association of American Medical College’s Center for Workforce Studies. Physician shortages to worsen without increases in residency training. Available at: https://www.aamc.org/download/286592/data/physicianshortage.pdf. Accessed March 4, 2013.