Looking forward – March 2017

David B. Hoyt

David B. Hoyt, MD, FACS

Topping the agenda of the new presidential administration and Congress is repeal of at least some portions of the Affordable Care Act (ACA). Many Fellows of the American College of Surgeons (ACS) have expressed concerns about the potential consequences of this effort, particularly if Congress passes replacement policies that have not been thoughtfully articulated and debated.

The ACS intends to play an active role in what is certain to be a highly charged debate—just as we did when the ACA was under consideration. As we enter this discussion, we will advocate for the policies that we believe will have the greatest benefit toward ensuring that all surgical patients have access to necessary services. We will not be swayed by politics, but rather will promote our enduring principles of meaningful change: quality and safety, patient access to surgical care, reduction of health care costs, and medical liability reform.

Quality and safety

The ACS maintains that quality improvement and patient safety efforts should be at the heart of health care reform. In our advocacy efforts, we will explain how the ACS uses a multifaceted approach to enhance quality and safety in health care worldwide. This process involves four steps: setting standards, building the infrastructure necessary to comply with the standards, using clinical registries to measure performance and guide improvement, and instituting peer review processes to verify adherence to evidence-based standards.

To promote quality improvement and patient safety, the College supports legislation and policies that advance well-designed clinical comparative effectiveness research, the analysis of physician quality data, appropriate public reporting, and the use and adoption of health information technology.

Patient access to surgical care

As L. D. Britt, MD, MPH, DSc(Hon), FACS, FCCM, FRCSEng(Hon), FRCSEd(Hon), FWACS(Hon), FRCSI(Hon), FCS(SA)(Hon), FRCSGlasg(Hon), ACS Past-President, has noted, “There is no quality without access.” It is essential that reforms lead to health care coverage that is more accessible and more affordable for all Americans. The ACA has led to an increase in the number of people who have health insurance coverage. We should seek to sustain these gains and expand upon them through the development of more affordable alternatives. One of the common criticisms of the ACA is that low-income Americans cannot afford to pay the rising premiums. We cannot allow new coverage paradigms to threaten access to surgical care for at-risk populations.

The ACS has a long-standing policy of supporting universal access to affordable, high-quality surgical care delivered in a timely and appropriate manner. To achieve this goal, the nation must have a well-trained surgical workforce that can meet the needs of all surgical patients. The ACS maintains that any health care reform plan should call upon the health insurance industry to address issues of cost containment, coverage for low-income patients and those with pre-existing medical conditions, and administrative burdens for providers.

Reduction of health care costs

ACS Quality Programs, such as the ACS National Surgical Quality Improvement Program, the Trauma Quality Improvement Program, the Cancer Quality Improvement Program, and so on, lead to higher quality care and cost savings by preventing inefficiencies and complications. Consequently, the College will advocate for continued payment reforms that promote participation in quality improvement efforts, including the development and testing of Advanced Alternative Payment Models (APMs). APMs should ensure a sustainable workforce by providing fair and appropriate reimbursement for surgeons (see related article). Cost containment should be linked to improvement in care. If implemented, participation should be voluntary, nonpunitive, and allow access to a range of providers.

In addition, the ACS maintains that Congress should retain primary responsibility for setting Medicare payment policy. This task should not be delegated to an unelected government body that accepts minimal input from patients and other stakeholders.

Medical liability reform

The mission of the ACS is to improve the care of the surgical patient, safeguard standards of care, and create an ethical practice environment. The College believes the nation’s medical liability system is broken and that it fails both patients and physicians. Whereas liability reforms enacted at the state level have effectively reduced health care costs and improved access to care, the College will advocate for reforms aimed at fostering safety, quality, and accountability; traditional tort reforms, including caps on noneconomic damages; and alternative, patient-centered reforms, such as early disclosure and offer programs, communication and resolution programs, and safe harbor protections.

Strategy going forward

We are living in an era of political polarization, and health care reform certainly has been one of the most divisive issues for a number of years. As a professional organization dedicated to providing surgical patients with optimal care, it behooves the College to play a part in this round of the debate.

We will urge Congress to take the College’s general principles into account as members develop a clear strategy for reforming the current policies. The ACS also will encourage legislators to provide opportunities for patients, health care professionals, and other key stakeholders to assess new proposals and to share their views on the best path forward.

In these exchanges, the College will be direct but civil and will be prepared to offer alternatives that we believe will serve the interests of surgical patients. No doubt, there will be—and, in fact, should be—disagreement. A certain amount of conflict and tension is necessary to stimulate change and growth. However, we cannot allow these discussions to deteriorate into discord and division.

For more than 100 years, Fellows of the ACS have been committed to serving all patients with skill and fidelity. Throughout our history, we have engaged with state and federal lawmakers on both sides of the aisle to advocate for the profession and our patients. The ACS leadership looks forward to a thoughtful reevaluation of the health care system in the months and years ahead.

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