Report on ACSPA/ACS activities: October 2012

American College of Surgeons Professional Association (ACSPA)

As of September 2012, the ACSPA-SurgeonsPAC (political action committee) raised $522,570 from a combined effort of 1,888 members of the College and staff. This was $137,230 more than what the ACSPA-SurgeonsPAC raised at the same point in 2011, and bringing a total of $1,188,261 raised for the 2011–2012 congressional election cycle. A total of 71 percent of the 214 U.S. Governors contributed $69,140 (average contribution $455). In the 2011–2012 cycle, the ACSPA-SurgeonsPAC contributed to 106 candidates, leadership PACs, and party committees. Find out more about the ACSPA.

American College of Surgeons (ACS)

Member Services

The Executive Committee of the Board of Governors met nine times (from January to October) via telephone conference calls. In addition, the committee met face-to-face twice during the 2012 Clinical Congress.

The Board of Governors’ annual survey communicated to the College’s leadership the concerns and recommendations of the Fellows regarding major issues in surgery. The results of the survey were presented to the Board of Regents for consideration, as this body determines future College endeavors. The top seven issues of concern to the Fellows of the College in 2012 as reported by the Governors are listed in the sidebar.

The Board of Governors also responded to a survey on general surgery residency education. Following are some of the findings:

• A total of 94 percent of the Governors said changes are necessary in general surgery residency education.
• A total of 75 percent stated that the current system of training residents allows chief residents to graduate with significant gaps in their education.
• A total of 56 percent stated they do not believe that general surgery chief residents have adequate surgical training to transition to the attending surgeon role.

The Board of Governors and the Board of Regents held a joint session during the annual business meeting of the Governors. The session featured keynote speakers R. Phillip Burns, MD, FACS, ACS First Vice-President; Frank R. Lewis Jr., MD, FACS, director of the American Board of Surgery; and J. David Richardson, MD FACS, Immediate Past-Chair of the Board of Regents. Their presentations focused on the future of surgical residency training.

The Board of Regents approved the Board of Governors’ Committee on Physician Competency and Health document titled Being Well and Staying Competent: Challenges for the Surgeon. The document replaces The Impaired Surgeon manual and will be posted on the Members-only section of the College’s website.

The Regents also approved a Statement on Concussion and Brain Injury. The statement was published in the December 2012 issue of the Bulletin and has been posted on the College’s website.

Operation Giving Back (OGB)

In October 2011, it was agreed that a letter would be sent to Nils Daulaire, MD, MPH, the U.S. representative to the World Health Assembly (WHA), in support of the concept that “development of healthcare systems for any nation must include access and support for appropriate surgical care and anesthesia in equal relationship to other critical healthcare components.” Efforts to support the Resolution for Surgery and Anesthesia continue on multiple fronts. A toolkit has been assembled with supporting research, talking points, sample letters, and published articles related to the importance of an official declaration of the need to support the surgical and anesthesia workforce, training, and patient access on a global scale. The toolkit is intended to supplement the presidential visits and assorted other efforts to inform and recruit support from international surgical leaders, including the College’s international Governors. Efforts are under way to garner support among U.S. representatives and senators to endorse these concepts and develop a formal resolution. For example, Fellows have met with U.S. senators to explore the most effective advocacy efforts that may be pursued with the U.S. delegate to the WHA.

The OGB received 16 requests for and distributed 436 copies of the recently discontinued eighth edition of the Advanced Trauma Life Support^® (ATLS^®) manual to ACS members involved in humanitarian activities. Recipients include surgeons working in Ecuador, Ethiopia, Haiti, Jordan, Malawi, Nepal, Philippines, Peru Sierra Leone, Thailand, Uganda, and Vietnam.

Other OGB activities include work in the following areas:

• International medical societies and health association network
• Medical student and resident issues
• OGB communications
• OGB publications
• Partnership activities and outreach
• Rwanda visit
• OGB-sponsored Clinical Congress sessions and events

During 2012, 44,066 unique visitors from 178 countries have accessed the OGB website approximately 121,930 times, which represents an increase in site traffic of more than 12 percent over the past year.

A total of 204 volunteer opportunities were published in various outlets, and 22 were new or updated opportunities. New partnerships have been established with the Rwanda Human Resources for Health Program and the National Association of Free and Charitable Clinics.

The number of surgeons who have completed profiles in “My Giving Back” has increased to approximately 2,000. The OGB website consists of 901 pages. It is also worth noting that Pfizer, Inc. has generously extended its support for OGB and the ACS/Pfizer Volunteerism and Humanitarian Awards for another year.

Resident Associate Society of the College (RAS-ACS)

The RAS-ACS continues to update all of its processes to allow greater transparency and increase membership. Projects include:

• Analyzing data from resident needs assessment survey
• Analyzing data from program directors survey
• Conducting essay competition
• Expanding international scholarships from one to four
• Revising Surgical Jeopardy expansion proposal
• Increasing RAS representation on College committees
• Moderating/co-moderating Clinical Congress session
• Leading Town Hall lectures at Clinical Congress
• Increasing social media presence
• Planning proposed spring RAS meeting

Young Fellows Association (YFA)

The YFA continues to update all of its processes to allow greater transparency and increase membership. Projects include:

• Presentation of a slide show during the robing of Initiates for Convocation, and YFA flyers in registration packets.
• Presentation of the annual Leadership Conference. The 2012 conference was well-attended and well-received, with participants giving positive feedback on the subject matter and format of sessions. The YFA is working closely with the ACS Division of Advocacy and Health Policy (DAHP) to expand the vision for future conferences.
• The Mentorship Program was expanded in 2012 from 10 mentors/mentees to 15.
• The YFA successfully secured a position on the ACS Program Committee.

Advocacy

The College worked on a number of advocacy and health policy issues this past year, including reimbursement, health care reform, medical liability, graduate medical education, and so on.

Reimbursement. The College led the physician charge to eliminate the sustainable growth rate (SGR) from the formula used to calculate Medicare reimbursement and to pay for the costs of repealing the SGR through the use of the unspent Overseas Contingency Operations (OCO) funds. The College pointed out that using the OCO funds would enable Congress to eliminate all of the accumulated and future scheduled payment cuts that the SGR has created, while producing a more accurate and fiscally responsible budget. Use of unspent OCO funds to offset the cost of repealing the SGR has almost universal support from organizations representing physicians, hospitals, and Medicare beneficiaries.

The College leadership met with key members of Congress to urge them to permanently repeal the SGR and to use war drawdown savings to do so. Despite the medical community’s hard work and the efforts of some legislators, Congress is poised again to postpone repeal and permanent reform. The College continues to urge Congress to find the political will to pass permanent repeal legislation and better serve patients. At the urging of the College and other groups, several members of the House of Representatives sent a letter to congressional leaders in support of moving forward with a permanent repeal of the SGR formula and offsetting the full cost of repeal with unused OCO funds.

On July 11, Frank Opelka, MD, FACS, Associate Medical Director of the DAHP, represented the College at a Senate Finance Committee roundtable titled Medicare Physician Payments: Perspectives from Physicians. On July 18, David Hoyt, MD, FACS, Executive Director of the College, spoke on Medicare payment reform during a House Energy and Commerce Health Subcommittee hearing titled Using Innovation to Reform Medicare Physician Payment. The goal of the roundtable and hearing was to explore possible options for replacing the flawed SGR formula used to calculate Medicare reimbursement. Drs. Opelka and Hoyt shared with key members of Congress the College’s experience with quality programs, such as the National Surgical Quality Improvement Program (ACS NSQIP^®), and discussed the framework of the College’s draft proposal for replacing the SGR.

Representatives of the College and several medical and surgical organizations discussed with key congressional staff concerns related to the Centers for Medicare & Medicaid Services’ (CMS) proposed rule on Stage 2 “meaningful use” for the Electronic Health Records (EHR) Incentive Program. The College and other provider groups crafted a letter to share with congressional staff that focuses on the unique challenges that physicians in small practices face with respect to implementing EHR, including limited finances, time, and staff. The letter also includes several specific concerns on criteria set in the proposed rule as well as suggested congressional actions and plausible fixes.

On August 24, 2012, CMS and the Office of the National Coordinator for Health Information announced the release of the highly anticipated Stage 2 final rule for the EHR incentive program. The Health Information Technology for Economic and Clinical Health Act states that eligible providers—including physicians, other health care professionals, and hospitals—
may qualify for Medicare and Medicaid incentive payments when they adopt and meaningfully use certified EHR technology. The College has been closely following the development of the EHR requirements and has issued comments to CMS concerning the Stage 2 proposed rule. At the time of the October 2012 Board of Regents meeting, the College’s DAHP staff was reviewing the final rule and intended to provide substantive details on the final rule.

The College sent a letter to CMS, expressing surgeons’ concerns regarding the fiscal year (FY) 2013 Inpatient Prospective Payment System (IPPS) proposed rule. The letter also offered support for a series of modifications to the proposal. On August 3, 2012, CMS released the final rule on the FY 2013 Medicare IPPS. Under the regulation, hospitals will receive, in the aggregate, a 2.3 percent payment increase over FY 2012 for inpatient care. In addition, the rule finalizes the inclusion of two illnesses on the hospital-acquired conditions list.

CMS also made a number of changes to the Hospital Inpatient Quality Reporting (IQR) program, including a reduction in the number of Hospital IQR program measures for FY 2015 from 72 to 59 and the addition of a safe-surgery checklist measure for FY 2016. In response to comments on the proposed rule, which was released earlier this year, CMS clarified that it is not mandating the use of a specific checklist with any required number of surgical timeouts; rather, hospitals and surgeons may adapt the checklist to fit their unique needs and environments. In addition, CMS did not finalize a proposal regarding the redistribution of residency slots, which could have negatively affected general surgery residencies.

On July 6, CMS released the proposed calendar year (CY) 2013 outpatient prospective payment system/ambulatory surgical center payment rule. The final rule was released November 1, 2012, and became effective January 1, 2013. The College analyzed the rule and submitted comments.

The Affordable Care Act (ACA) requires that CMS implement a value-based payment modifier that would apply to Medicare fee-for-service payments starting with some physicians on January 1, 2015, and to all physicians and groups by January 1, 2017. The value-based payment modifier is intended to pay physicians differentially based on the quality of care they provide and the cost of that care. It would incorporate the use of physician feedback reports, which are confidential reports that quantify and compare the quality of care furnished and costs among physicians and physician group practices, relative to the performance of other physicians. The College submitted a letter that discusses proposals on the value-based payment modifier.

Health care reform. The U.S. Supreme Court issued its ruling on the ACA last summer. The Court upheld the entire law with a small exception related to the federal government’s power to terminate state Medicaid funds. The College will continue to support prudent implementation of those provisions of the law that benefit surgeons, surgical care, and surgical patients as well as work to change those aspects that are not beneficial. Both political parties and most stakeholders agree that change must occur within our health care system. However, the vigorous public debate over the ACA reflects wide differences of opinion on the best pathway to reform. The College remains focused on its mission of advancing its health policy agenda, which seeks to safeguard the surgical patient and create a practice environment that is conducive to surgeons’ ability to uphold the highest professional standards. The ACS maintains that any new health care system must promote quality care, improve patient access, and, ultimately, reduce costs while improving patient outcomes.

The ACS Inspiring Quality campaign—an important part of a century of implementing quality improvement programs—has demonstrated the potential to make positive changes to the nation’s health care delivery system. Ensuring patients have access to consistent, high-quality care is a central pillar of real health care reform. It puts the patient first and supports physicians as the drivers of change. The challenges facing the health care system, including Medicare, are complicated and carry significant fiscal implications as well as the potential for unintended consequences on access to care. The College believes every physician and health care provider should commit to being a responsible steward of the nation’s health care resources and work to find a balance between fiscal prudence, the delivery of high-quality care, and preservation of the physician-patient relationship.

Medical liability. The Emergency Medical Treatment and Active Labor Act (EMTALA) mandates that a physician provide care to stabilize all patients who present at a hospital emergency department regardless of their ability to pay. The poor likelihood of reimbursement and high-liability risk associated with the complex, high-risk surgical care provided for severely injured patients who present in an emergency department are broadly acknowledged as the key factors contributing to the growing shortage of specialists participating in emergency on-call panels. The Health Care Safety Net Enhancement Act (H.R. 157)—legislation introduced by Rep. Pete Sessions (R-TX)—would address this growing problem by providing Public Health Service Act liability protections for physicians providing EMTALA-mandated care. On March 22, 2012, the House passed by voice vote an amendment introduced by Reps. Charlie Dent (R-PA) and Sessions that attached H.R. 157 to the Protecting Access to Healthcare Act of 2011 (H.R. 5), which the House also passed.

H.R. 157 language was included as an amendment to H.R. 5, which, among other provisions, calls for repealing the controversial Independent Payment Advisory Board established under the ACA and seeks to institute medical tort reform across the country. The College will continue to advocate for this important legislation.

Graduate medical education. The College submitted letters that were circulated in both chambers of Congress in support of funding in FY 2013 for the Children’s Hospital Graduate Medical Education (GME) Payment Program. Administered by the Health Resources and Services Administration, the program provides federal funds to the nation’s freestanding children’s hospitals to help them maintain their GME programs.

Workforce. A growing body of evidence points to a worsening shortage of surgeons available to serve our nation’s aging and growing population. With this looming crisis in the surgical workforce, the College is concerned that focusing efforts only on specialties that fall under the broad rubric of primary care could have severe consequences for surgical patients. The ACS supports primary care physicians and acknowledges that they provide a needed service for all patients. However, primary care can be provided by a spectrum of health care professionals. In contrast, surgeons are uniquely qualified to perform necessary and lifesaving procedures that no other professional is trained to safely and effectively provide. Surgery and surgical patients are under great stress because the number of physicians who are qualified to provide surgical services to patients is declining. The College has been fighting to ensure that patients continue to have access to high-quality surgical care by supporting policies and initiatives that will strengthen the surgical workforce.

The College’s Health Policy Research Institute (ACS HPRI) released updated maps that illustrate the distribution of surgeons and general surgeons per 100,000 population across the U.S. in 2006 and 2011. The maps track the “absolute” and “percentage” change in surgeons per population for the same period. The data are reflective of all 3,107 U.S. counties. Similar maps for surgical subspecialties will be added this year. The ACS HPRI is also working to distribute an updated Surgery Workforce Atlas—a Web-based set of maps that shows, county by county and state by state, where shortages of surgeons and other physicians threaten patient access to high-quality, affordable care.
The College supported the Resident Physician Shortage Reduction Act of 2011 created to bolster the surgical workforce and the health care infrastructure by increasing the number of residency positions. The Act expands the number of Medicare-supported physician residency training positions by 3,000 annually from 2013 through 2017.

Significant research conducted by the ACS HPRI was highlighted during a recent interview conducted by C-SPAN’s Washington Journal host, Steven Scully. Mr. Scully and Atul Grover, MD, chief public policy officer at the Association of American Medical Colleges, discussed various health care issues, including the shortage of physicians across the nation. Dr. Grover indicated that ACS HPRI projections show a decrease of 3,340 active practice surgeons between 2013 and 2028 if the number of surgeons trained remains flat and if GME caps remain in place. The caps were included in the 1997 Balanced Budget Act and froze the number of residents for which a hospital could claim Medicare payment based on the number of residents each hospital trained in 1996. Presently, Medicare limits the number of training programs it supports at approximately 80,000.

Just before the start of the August 2012 recess on Capitol Hill, the Senate passed a three-year extension to the current Conrad State 30 Program through September 30, 2015. (The program was set to expire at the end of September 2012.) In July, Dr. Hoyt sent a letter in support of the Conrad State 30 Improvement Act, which seeks to expand and permanently reauthorize the Conrad State 30 Program. This program allows international physicians who are in the U.S. on J-1 visas to obtain a waiver of the J-1 requirement to return home for two years in exchange for three years of practice in medically underserved areas. Each state is currently allowed 30 waivers per year, and the program has brought thousands of physicians, including surgeons, to rural and underserved communities in all 50 states. This legislation has been referred to the Senate Committee on the Judiciary for consideration.

American College of Surgeons Foundation

Foundation history highlights are listed in the sidebar. What is next?

• A compelling “case for support” that explains value proposition for philanthropy
• Greater differentiation of benefits for major donors
• Greater peer-to-peer fund seeking activity
• Emphasis on major gifts to support major programs
• Deferred and legacy giving: Mayne Heritage Society
• Engagement in giving by foreign-born Fellows now in U.S.

Communications/public profile

The Bulletin of the American College of Surgeons redesign debuted in September 2012. The newly designed publication reflects a number of enhancements intended to increase reader engagement. In addition, a Bulletin microsite has been created to provide a Web-based alternative to the print version. The microsite eventually will also contain some Web-exclusive Bulletin features.

Since the hiring of a full-time Communications Manager for the Washington Office, the College has steadily increased its communications to Fellows regarding advocacy and health policy initiatives on their behalf. Most notable was the August launch of a monthly e-newsletter titled The ACS Advocate.

As part of the ACS Centennial celebration, the College has produced two publications. A Century of Surgeons and Surgery: The American College of Surgeons 1913–2012 is a hardcover book that provides a detailed historical account of the College’s first 100 years. The second publication, titled Remembering Milestones and Achievements in Surgery: Inspiring Quality for a Hundred Years 1913–2012, is a collection of articles by luminaries on milestones across the surgical specialties. Both publications were given as gifts to all attendees at the 2012 Clinical Congress.

To showcase the past century of leadership, innovation, and quality surgical care, and to celebrate the ACS’ 100th anniversary, the College developed an interactive historical timeline. The timeline, unveiled at Clinical Congress, will be shared via traditional and social media networks.

During 2012, the College made considerable progress in creating a strong social media presence for the College. The following statistics demonstrate this:

• Facebook: 1,717 “likes”
• Twitter: 6,063 followers
• YouTube: 217 subscribers

The recently completed content audit and strategy development for the online properties were the precursors to the redesign of the College’s public website and the integration of what is now the members’ portal into the main site, with password-protected member-only content.