The Board of Directors of the American College of Surgeons Professional Association (ACSPA) and the Board of Regents of the American College of Surgeons (ACS) met during the 2014 Clinical Congress in San Francisco, CA. Following is a report of the their discussions and actions.
As of the October meeting, the American College of Surgeons Professional Association’s political action committee (ACSPA-SurgeonsPAC) had raised $467,990 in both personal and corporate funds from 1,531 American College of Surgeons (ACS) members and staff, with an average contribution of $306. Of this amount, $421,475 is personal (hard) dollars and $46,515 is corporate (soft) dollars.
In the 2014 election cycle, the PAC contributed $1,053,500 to 151 candidates, leadership PACs, and party committees. Of this amount, 60 percent was given to Republicans and 40 percent to Democrats.
The ACSPA-SurgeonsPAC has been making an increased effort to encourage ACS members to deliver SurgeonsPAC checks to their legislators’ in-district offices as a step toward developing long-term relationships with key elected officials. In the six months preceding the Clinical Congress, more than 30 PAC checks were delivered to members of Congress and congressional candidates.
Division of Advocacy and Health Policy
The College’s top-ranking advocacy and health policy initiatives include the following:
- Medicare physician payment
- Medical liability reform
- Workforce/graduate medical education
In September 2014, leadership from the ACS, American Medical Association (AMA), American College of Physicians, American Academy of Family Physicians, and American Osteopathic Association met with senior congressional leadership to explain why Congress should repeal the sustainable growth rate (SGR) formula used to calculate physician reimbursement. Patrick V. Bailey, MD, FACS, Medical Director of Advocacy, ACS Division of Advocacy and Health Policy, represented the College.
The 96-hour rule
The Centers for Medicare & Medicaid Services (CMS) recently indicated it would begin enforcing a long-forgotten regulation requiring that physicians who admit patients to critical access hospitals (CAHs) certify that each patient can reasonably be expected to be discharged or transferred within 96 hours. Previously, CAHs operated under a similar but separate condition of participation that required patient stays to be under 96 hours on average. As a result of CMS’ action, surgeons will be unable to admit patients for procedures routinely performed in CAHs, and many patients will be forced to travel further from home for treatment. To address the issue, Rep. Adrian Smith (R-NE) and Sens. Pat Roberts (R-KS) and Jon Tester (D-MT) have introduced legislation—the Critical Access Hospital Relief Act (H.R. 3991/S. 2037)—to eliminate the certification requirement and maintain the 96-hour average stay requirement. The College has endorsed the bill.
21st century cures
The House is reviewing the nation’s response to scientific and technological advances. Late last year, the House held listening sessions with support and participation from research institutions, consumer groups, the National Institutes of Health, and pharmaceutical and biotech organizations.
The Affordable Care Act authorized funding for loan repayments for pediatric subspecialists, including pediatric surgeons, who agree to practice in workforce shortage areas for at least two years. The College sent a letter to appropriators asking that $5 million be allocated to the program. Unfortunately, monies for the program were omitted from the omnibus appropriations bill that funded the government for the remainder of the fiscal year (FY). The College also signed on to a coalition letter to the Office of Management and Budget asking the Administration to request that $5 million be appropriated to the Health Resources and Services Administration to fund the program. Program authorization is set to expire after the current fiscal year; Rep. Joe Courtney (D-CT) has recently introduced legislation that would extend this authorization through FY 2018. The ACS supports this legislation.
Misvalued physician service codes
The most recent one-year SGR patch included the misvalued services provision that was part of the larger SGR Repeal Act. The legislation allows the Secretary of the Department of Health and Human Services (HHS) to revise payments for potentially misvalued codes within the physician fee schedule based on information collected from providers, as follows:
- The policy applies to the fee schedule for the years 2017–2020.
- The target for value reduction is 0.5 percent of the estimated amount of total fee schedule expenditures for the given year.
- If the total relative value unit for an identified misvalued code is scheduled to be reduced by 20 percent or more due to the reevaluation, the adjustment must be phased in over two years.
The College has long opposed this provision, noting that the AMA Relative Value Scale Update Committee and CMS have been working for a number of years to revalue all codes; this work is expected to continue through 2016.
CMS recently announced that physicians and teaching hospitals may register in the CMS Enterprise Portal to request access to the Physician Payments Sunshine Act (PPSA) open payments system in July. Although the PPSA does not require physicians to take action, nor does it impose any penalties on physicians, registration is required for physicians and teaching hospitals to review and dispute reported information.
National Quality Forum
Clifford Y. Ko, MD, MS, MSHS, FACS, Director, ACS Division of Research and Optimal Patient Care, serves as the ACS representative on the National Quality Forum (NQF) Surgery Standing Committee, which identifies and endorses performance measures for a number of surgical disciplines, including cardiac, thoracic, vascular, orthopaedic, neurosurgery, urologic, and general surgery.The ACS continues to have representation on the NQF Measure Applications Partnership (MAP), a public-private partnership convened by the NQF for providing input to HHS on selecting performance measures for public reporting, performance-based payment, and other programs. Eric Whitacre, MD, FACS, a breast surgeon in Tucson, AZ, serves as a technical expert to the NQF MAP Clinician Workgroup.
Surgeons have become more active in sending letters to their state legislators through the Surgery State Legislative Action Center. Typically, 15 to 20 letters are sent when an action alert e-mail goes out to surgeons in a particular state. In 2014, however, a large number of letters were sent, including the following:
- New York surgeons made clear their support for truth in advertising legislation by sending 163 letters, supported changes in payment for out-of-network coverage with 127 letters, and opposed some liability-related legislation with 287 letters.
- Louisiana surgeons sent 208 letters supporting coverage for bariatric surgery and sent 148 letters opposing expansion of scope of practice for optometrists.
- California surgeons helped to defeat optometric scope-of-practice expansion legislation by sending 133 letters.
AMA House of Delegates
The College sent five delegates to the annual meeting of the meeting, June 7–11, 2014, in Chicago, IL: John H. Armstrong, MD, FACS; Jacob Moalem, MD, FACS; Leigh Neumayer, MD, FACS; Richard Reiling, MD, FACS; and Patricia L. Turner, MD, FACS. Assisting the delegation was Timothy Kresowik, MD, FACS, a vascular surgeon from Iowa, and Kenneth Louis, MD, FACS, a neurosurgeon from Florida. With this meeting, Dr. Reiling completed his 22-year tenure as a member of the ACS delegation. He chaired the delegation from 2006 through 2010 and was the first Fellow to be elected to an AMA Council as a nominee of the College. The delegation recognized his leadership, and he was on the list of retiring delegates presented to the HOD.
Chapter Lobby Day Grants 2015
Chapters were asked to apply for lobby day grants in 2015. Under the program, chapters may receive up to $5,000, with the expectation that the chapters provide a 50 percent match. In 2014, 17 states received a grant. As of the October board meeting, the Health Policy and Advocacy Group (HPAG) confirmed that the following chapters would be receiving grants for 2015:
- Brooklyn/Long Island
Other states expecting to conduct lobby days in 2015 are Louisiana, North Carolina, Ohio, Oregon, Texas, and Washington.
The Commission on Cancer (CoC) has accredited a total of 1,507 cancer programs in the U.S. and Puerto Rico. Annually, these centers treat 71 percent of all newly diagnosed cancer patients. The CoC conducted 433 cancer program surveys in 2013–2014, and 27 new cancer programs joined the accreditation program. The CoC presented Outstanding Achievement Awards to 79 cancer programs, and eight new physician and nonphysician surveyors were recruited and participated in initial training.
CoC’s Best Practices Repository was reformatted, and additional content was approved by the Standards Advisory Group for Excellence. In addition, the site for CoC Accreditation was launched for distribution of certificates and Outstanding Achievement Award trophies and the purchase of related promotional materials. Furthermore, in 2013, more than 1,000 individuals registered on the CAnswer Forum site, and more than 2,000 questions were submitted. Most inquiries focused on cancer registry coding guidelines.
The National Cancer Data Base’s (NCDB) Cancer Program Practice Profile Reports have been expanded to include two new sets of quality measures. Three breast measures were released in March 2014. Three additional measures will be included along with the 2012 data release, two for non-small cell lung and one for gastric, bringing the total released measures to 12. Multiple societies are collaborating to develop and harmonize additional measures to be evaluated by the Quality Integration Committee, and, if approved, implemented through an NCDB reporting tool.
Interest in the NCDB Participant User File (PUF) program grew in 2014; 227 applications (up from 178 the previous year) were reviewed for technical feasibility of research aims. Researchers using PUF data have generated 19 breast, 15 colorectal, nine esophagogastric, one melanoma, three ovarian, three pancreas, one sarcoma, two thyroid, and four bladder papers/presentations.
The number of programs participating in the Rapid Quality Reporting System (RQRS) grew in 2013–2014 from 54 percent of CoC-accredited programs/networks to 71 percent currently.
The Prospective Payment System (PPS)-exempt contract, received in October 2012, completed its second year. The 11 members of the Alliance of Dedicated Cancer Centers (ADCC) submitted data to the RQRS system. Quarterly data files containing quality measure rates for three measures (two for breast cancer, one for colon) are generated and submitted to CMS for public reporting. CMS hosted a meeting in June 2014 with representatives of the facilities and contractors to discuss progress to date. The ACS received notice of renewal for the second option year of the contract in September 2014.
The CoC’s second Annual Advocacy Committee Planning Meeting took place in San Francisco, CA, on October 25, 2014. The CoC has been actively engaged in several legislative and regulatory policy issues this quarter, including support of the AMA resolutions on genetic testing and biomedical researchlegislation.
The College’s Clinical Research Program (ACS CRP) Cancer Care Standards Development Committee has submitted the manuscript, Operative Standards in Cancer Surgery, to the publisher. Production began in September 2014, with a targeted publication date of February 2015. All 23 CoC-accredited institutions have volunteered to pilot-test the data collection tool and electronic interface; pilot-testing began in September 2014.
In addition, the ProvenCare Lung Cancer Collaborative leadership met to discuss the expansion of the collaborative to include medical and radiation oncology. Data elements for these specialties have been developed and will be finalized through conference calls in October 2014. The expanded program, Phase III, is set to launch in early 2015, in which nine institutions are participating.
Content development for the American Joint Committee on Cancer (AJCC) Cancer Staging System 8th Edition began in October 2014. The infrastructure is now in place to support more than 500 volunteers, 18 expert panels, five cores, and the editorial board. The AJCC continues to administer the Collaborative Stage Data Collection System (CS) through a cooperative agreement with the Centers for Disease Control and Prevention (CDC). Collaborative Stage CS Version 02.05 was released in November 2013.
Two new educational presentations were developed specifically for the registrar community to assist in the transition from CS to directly coded AJCC Staging. This transition will take place January 1, 2016. The CDC has provided funding for the development of educational offerings. The initial two presentations were made available for the state registrar meetings, and over the coming year an additional 12 presentations will be rolled out as part of a comprehensive curriculum from registrars to reinforce their knowledge of AJCC staging.
The National Accreditation Program for Breast Centers (NAPBC) has now accredited more than 560 breast centers in the U.S. Reaccreditation rates for 2014 and 2015 remain at 99 percent. Approximately 20 percent of centers request to be surveyed with their CoC program. A small team of cross-trained surveyors perform these collaborative surveys. Efforts are under way to validate NAPBC-accredited centers that are affiliated with a CoC program.
The CoC collected video testimonials from Survey Savvy attendees. The videos have been completed, are being used at trade shows, and will be posted to the College’s YouTube channel.
Division of Education
The Committee on Residency Training (“Fix the Five”) has met regularly and has identified seven principal areas of focus:
- Organizational commitment
- Transitions during surgery residency
- Structured curricula, assessment, proficiency-based training and advancement
- Appropriate autonomy for residents
- Environment of residency education, including duty hours, fiscal resources, and support systems
- Faculty development and support; identification and dissemination of best practices
- End product of surgery residency training
The committee will continue its deliberations and plans to support innovative pilot projects that will help to transform surgical education and training. Best practices from experiences across the country will be widely shared.
The ACS Clinical Congress remains the premier annual surgical meeting and provides a broad range of outstanding education and training opportunities for surgeons, surgery residents, medical students, and members of surgical teams. In 2007, a strategic planning process that involved two retreats of the Program Committee resulted in transformational changes in the Clinical Congress program, including the introduction of tracks composed of blocks with uniform start and end times, addition of Meet-the-Expert Luncheons and Town Hall Meetings, and expansion of the range of Skills Courses.
In preparation for the retreats, a number of task forces were appointed and charged with the responsibility of critically reviewing various components of the Clinical Congress program and developing recommendations for further enhancements. The retreats were extremely productive and resulted in several recommendations that will help to take the Clinical Congress program to another level.
The Board approved the establishment of an ACS Academy of Master Surgeon Educators. This Academy will play a critical role in providing recognition for Master Surgeon Educators, advancing the science and practice of leading-edge surgical education and training; fostering the exchange of creative ideas and collaboration; supporting faculty development and recognition; and underscoring the importance of surgical education and training in the changing health care environment. This Academy will complement the new Education and Training Campaign that the College launched at Clinical Congress 2014, as well as activities of the Committee on Residency Training, the Transition to Practice Program, and other education and training activities.
Division of Member Services
As of September 1, 2014, the College comprised 78,361 members—36,864 of whom are dues-paying Fellows. A total of 1,676 applications for Fellowship were evaluated in 2014 by the College’s credentials committees. Of these applicants, 1,640 surgeons from the U.S., Canada, and 61 other countries, having been determined to have met all requirements for Fellowship, were approved by the Board of Regents, and were granted Initiate status.
The Board of Regents accepted resignations from 16 ACS Fellows. In addition, the College is surveying all dues-paying Fellows and Associate Fellows; a separate version of the instrument will be deployed to recently lapsed members. The two surveys are intended to determine how the College could be of greater value to members.
To further boost retention and recruitment of members, in January the College launched a Young Surgeons Marketing Campaign—Realize the Potential of Your Profession. A Show Your Pridecampaign also has been launched to reinforce use of the FACS insignia and encourage pride in Fellowship. Specialty-by-specialty recruitment strategies are being employed, along with efforts to increase membership and international outreach.
Other retention and recruitment activities are as follows:
- Following the 2013 Clinical Congress, each new Fellow received a welcome letter from ACS Executive Director David B. Hoyt, MD, FACS, along with their membership ID card and instructions on how to update their electronic profile and download FACS artwork. Additionally, they received the new member benefits brochure and a complimentary FACS pen.
- In December 2014, all Fellows received a personalized e-mail or letter thanking them for their membership in the College and informing them about how to contact their current Governor and Advisory Council chair to voice their concerns about issues affecting their geographic location or specialty.
- In January 2014, the new member benefits brochures were mailed to all International Fellows, Associate Fellows, Residents, and Medical Student members, and have been made available in hard copy or via e-mail to any surgeon leader, chapter, or program of the ACS.
To engage members at all levels of the College’s leadership structure, the ACS is evaluating the committee nomination and member engagement processes, conducting a member and non-member survey, coordinating the ACS response, deploying the Leadership Guide as a reference tool for members, and providing opportunities for members to become more involved in College committees and leadership positions.
This division is also responsible for managing the College’s governance and internal structures. It is responsible for reviewing the current membership application and related processes to improve efficiencies, centralizing scholarship and fellowship offerings within the Division, creating a Maintenance of Certification (MOC) calendar, conducting chapter-by-chapter needs assessment, completing the redesign of the role of the Advisory Councils, and more fully engaging leadership in personal interaction with members.
After an evaluation of their role and function, a workgroup has recommended a restructuring of the 13 Advisory Councils; the evaluation results have been shared with each council.
The Advisory Council for Rural Surgery, in conjunction with the Mithoefer Center for Rural Surgery, sponsored the Rural Surgery Symposium in May 2014 in Chicago. The symposium drew 54 attendees and faculty and focused on advocacy, economics, and patient care issues.
The Advisory Councils are developing a list of reasons to join the College.
The College now has 106 chapters: 67 domestic and 39 international. The newest domestic chapter to be approved was Guam, led by ACS Governor Ricardo Eusebio, MD, FACS.
Currently, 274 individuals serve on the ACS Board of Governors.
The newest chapter and specialty society Governors are from Guam, Nigeria, and the American Hepato-Pancreato-Biliary Association.
The Board of Governors welcomed 33 Governors-at-Large and 13 specialty society Governors at Clinical Congress 2014.
The Resident and Associate Society (RAS) has reached out to specialty surgeons in several ways: jointly sponsoring a “meet and greet” with the Advisory Council for Pediatric Surgery following the Pediatric Surgery Forum at the Clinical Congress; distributing informational materials at the American Society of Plastic Surgery’s Chief Resident Day session; and developing a plan to engage thoracic surgical trainees via the Joint Committee on Thoracic Surgical Education.
The Young Fellows Association’s (YFA) Mentorship Program, now in its third year, has paired 22 young Fellows with ACS leaders to encourage young surgeons’ career-long involvement in the College. Plans are under way to expand this program.
Other YFA activities are as follows:
- During the 2014 Clinical Congress, the YFA sponsored two Town Halls Meetings, one Meet-the-Expert Luncheon, and three Panel Sessions.
- New this year is a multi-purpose video offering positive and light-hearted commentary from family members about the realities of life with a surgeon, and about the effect that surgeons have on their families. New Initiates viewed the 10-minute video during the Convocation robing at Clinical Congress 2014. The YFA intends to add to this project and post these videos on the YFA Web page and in the ACS Communities.
- The YFA held its first essay contest and reviewed seven submissions on the topic, The Promise of a Profession Lies within Us. The winning essay was published in the October 2014 issue of the Bulletin.
- The Young Surgeons Marketing Campaign is a major initiative intended to build broad awareness and understanding of the benefits of ACS membership.
Research and Optimal Patient Care
A total of 561 hospitals currently participate in the ACS National Surgical Quality Improvement Program (ACS NSQIP®), 500 of which are Adult ACS NSQIP sites. The Essentials option has the highest enrollment of all the adult participation options with 255 sites; the Procedure Targeted option, with 191 hospitals, has the highest level of growth.
The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) continues to grow and evolve since the unification of the ACS Bariatric Surgery Center Network and the American Society for Metabolic and Bariatric Surgery (ASMBS) Bariatric Surgery Center of Excellence. Of the 751 centers that participate in the MBSAQIP, 627 are fully accredited, 46 are data collection centers, and 78 are applying for accreditation. Expanding the accreditation options to include varying levels and surgical volume expectations—Comprehensive, Band, Low Acuity, and Comprehensive with Adolescent Qualifications—allows more centers to participate in MBSAQIP.
The soon-to-be-launched Decreasing Readmissions through Opportunities Provided (DROP) quality improvement initiative will enroll 75 MBSAQIP participating centers nationwide in an effort to reduce 30-day postoperative readmissions by 20 percent through the use of prescriptive patient intervention bundles. The MBSAQIP may then use program data to inform meaningful changes in the clinical care of patients, as well as examine resource utilization and cost containment in metabolic and bariatric surgery.
The MBSAQIP continues to expand its market presence by participating at national meetings. MBSAQIP staff attended the ASMBS’s First Annual National Obesity Collaborative Care Summit in September 2014 in Chicago. More than 40 thought leaders and health care providers representing more than 20 societies, including two payors, attended the summit, allowing participants to network for future collaboration in providing and coordinating care to the obese population. This meeting will continue annually in pursuit of the development of standards and guidelines for the multidisciplinary care of obese patients.
The MBSAQIP planned a significant presence at the annual ObesityWeek meeting, which the ASMBS and The Obesity Society sponsor to attract professionals who treat obesity and obesity-related illnesses. The MBSAQIP exhibit booth and staff at the meeting will offer attendees on-site access to clinical and statistical support. Staff will also participate in three distinct presentations and panel discussions presenting a review of the MBSAQIP, national initiatives, and the role of bariatric coordinators and data collectors. The expanded presence of the MBSAQIP at ObesityWeek helps to advance collaboration between the ACS and ASMBS.
Development of the ACS Quality Manual is under way. Quality Manual author groups submitted draft manuscripts mid-summer of 2014, which are under review.
The College celebrated the 10th anniversary of the Joan L. and Julius H. Jacobson II Promising Investigator Award at the 2014 Clinical Congress. Various events and sessions held during the Clinical Congress recognized Dr. and Mrs. Jacobson, as well as all the recipients over the past decade. Carrie A. Sims, MD, FACS, a general surgeon from Pennsylvania, was honored as the 10th recipient of the Jacobson Promising Investigator Award.
The ACS and the Armstrong Institute for Patient Safety and Quality piloted a one-day surgeon leadership course at the 2014 Clinical Congress. Surgeons participated in this course, which featured national quality improvement (QI) leaders. The course’s primary goal is to introduce QI and data review, present engagement strategies and QI models, and discuss strategies for overcoming barriers. First steps for initiating quality improvement in a surgical practice or hospital will be emphasized. Participant feedback will shape subsequent course development, and attendees will receive 6 AMA PRA Category 1 Credits™ upon completion.
The Outcomes Research Course, sponsored by the Surgical Research Committee, took place December 4–6, 2014, at ACS headquarters in Chicago. Thirteen faculty members led a combination of didactic lectures, work-in-progress sessions, and breakouts that allowed participants to select modules appropriate to their skill level and professional interests.
The ACS Clinical Scholars in Residence Program is a two-year on-site fellowship in applied surgical outcomes research, health services research, and health policy, offering surgery residents a unique opportunity to work with the College. Clinical scholars become embedded with the ongoing QI initiatives in the various programs. The application process for 2016–2018 appointments began January 1 and runs through April 1, 2015.
American College of Surgeons Foundation
As of October 2014, the 1913 Legacy Campaign had met 46 percent of its $5 million goal.
Throughout the Campaign, the Foundation sought industry support in collaboration with volunteers and ACS leadership. Top prospects were engaged through presentations, visits, and proposals, with participation by Dr. Hoyt, program staff, volunteers, and a campaign consultant.
Journal of the American College of Surgeons
Over the last five years, the number of submissions of original scientific manuscripts to the Journal of the American College of Surgeons (JACS) has increased by 49 percent. The increase in scientific papers JACS receives will positively affect the journal’s impact factor. In 2013, measuring citations from 2011 and 2012, JACS’ impact factor was 4.5, ranking ninth out of 202 surgery journals.
In addition to the 300-plus Surgical Forum abstracts published in the September supplement in print and online, approximately 600 abstracts from the 2014 Clinical Congress, including Scientific Papers and Scientific Poster Presentations, were published online and can be accessed through the JACS mobile app.
More than 3,500 Fellows per year earned MOC credit from JACS’ CME program in 2013–2014, a 3.8 percent increase from 2012–2013.
The JACS Twitter feed, @JAmCollSurg, has promoted featured articles, coverage of JACS articles in the news media, and important articles that generate buzz on Twitter. Since Lillian Kao, MD, FACS, joined JACS as Social Media Editor, the number of surgeon-followers for JACS has more than doubled, and she has facilitated conversations about JACS content.
JACS articles are being picked up by national media as a result of JACS collaboration with the ACS Public Information team.
Finally, the College expresses its appreciation to the 2013–2014 Officers: Layton F. Rikkers, MD, FACS, First Vice-President; John T. Preskitt, MD, FACS, Second Vice-President; and Carlos A. Pellegrini, MD, FACS, FRCSI(Hon), President. The College also thanks Gary L. Timmerman, MD, FACS, and Lorrie A. Langdale, MD, FACS, for their service as Chair and Secretary, respectively, of the Board of Governors.