Looking forward – October 2018

David B. Hoyt, MD, FACS

The mission statement of this organization is as follows: “The American College of Surgeons is dedicated to improving the care of the surgical patient and to safeguarding standards of care in an optimal and ethical practice environment.” This statement underscores the College’s enduring commitment to surgical education, quality improvement, and accreditation. It reflects the values of the American College of Surgeons (ACS) founders and of the surgeons who apply for Fellowship today.

For the last 50 years, a key part of ensuring that surgeons can provide quality care to all surgical patients has meant responding to our members’ concerns about funding for resident education, reimbursement from Medicare and Medicaid services, medical liability, and administrative burdens. The ACS has always sought to be responsive to these challenges and continues to do so today.

We recognize that recent transformations in the health care ecosystem have made it increasingly difficult for surgeons to pursue what has traditionally been an attractive model for delivering care—private practice. Rest assured that the College is as committed to preserving the viability of private practice as it is to promoting the research and surgical education standards that lead to better patient care. We recognize that private practice surgeons continue to play a fundamental role in ensuring that surgical patients have access to the care they need.

Responding to the changing environment

Surgeons and other physicians in the U.S. first began to lose a sense of ownership over patient care with the establishment of Medicare and Medicaid in the mid-1960s. Until then, organized medicine was powerful, prosperous, sovereign, and autonomous, and we as physicians and surgeons controlled hospital residency programs. Large, for-profit hospitals and health care systems were virtually nonexistent.

As Medicare expanded to provide coverage to more beneficiaries, including people with disabilities and end-stage renal disease, and the concept of health management organizations to control spending emerged in the early 1970s and ballooned in the 1980s, surgeons began to feel more constrained in their ability to practice as they wished. The College responded to the Fellows’ concerns in 1974 with the establishment of what was then known as the Division of Surgical Practice in the Chicago, IL, headquarters, which was charged with analyzing trends in payment, surgical disease, and the surgical workforce and developing policy. This division evolved into the Socioeconomic Affairs Department with the establishment of a small Washington office in 1979.

As times changed and the government and other payors continued to exert more influence over how physicians get paid and how they practice, starting with the development of the Medicare fee schedule in the early 1990s, many surgeons, particularly those in private practice, grew restive. The College responded by transforming the Socioeconomic Affairs Department into the Division of Advocacy and Health Policy (DAHP), which now is based entirely in Washington and is fully staffed by lobbyists who have worked on Capitol Hill and by regulatory and quality experts. These individuals work tirelessly at the federal and state levels to seek passage of legislation and address regulations centered on Medicare payment, coverage for out-of-network care, professional liability, and administrative burdens, including those associated with the electronic health record.

Where are we now?

Nonetheless, despite these efforts, practicing surgeons still feel squeezed. On one side, they feel they must jump through a tangle of administrative hoops to receive reimbursement that they believe is incommensurate with the services they provide. On the other side, they are sensing a loss of autonomy as large for-profit health systems impose new restrictions on how they provide care and which patients they see as out-of-network providers. The increase in for-profit health care systems has resulted in a greater focus on the bottom line.

Some surgeons have responded by choosing to become institutional employees. Under this option, the institution covers their overhead expenses, including their medical liability costs; provides office space and administrative staff; and offers benefits, such as paid vacation time and health insurance coverage.

A few years ago, the ACS DAHP responded to this trend, publishing a primer for surgeons interested in going this route—Surgeons as Institutional Employees: A Strategic Look at the Dimensions of Surgeons as Employees of Hospitals. New issues related to contract negotiation have emerged since the primer was released, with some agreements now coming up for renewal one year after signing, adding non-compete clauses, limiting benefits only to employees and not their families, and so on. The ACS has created an updated primer to address these issues.

Other surgeons prefer to remain in private practice and believe that the College should do more to help them get adequate reimbursement, deal with American Board of Surgery recertification problems, comply with regulatory mandates for meaningful use of the electronic health record, and address medical liability concerns.

Taking action

As an umbrella organization, the ACS seeks to be responsive to the concerns of all surgeons, regardless of where they practice or their specialty. For the last few months, we have been talking with Fellows in private practice and will convene a forum to identify problems and work on solutions. Our entire leadership, including the Board of Regents, Officers, and Board of Governors, along with my office, is committed to helping address these challenges.

For this initiative to succeed, we need your involvement. Please reach out to me, your Governor, a Regent, an Officer, or the staff in the DAHP. The ACS is here to ensure that you can continue to provide high-quality surgical care to the surgical patient. It is our raison d’etre.


If you have comments or suggestions about this or other issues, please send them to Dr. Hoyt at lookingforward@facs.org.

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