The American College of Surgeons (ACS) hosted its second annual Advocacy Summit, April 14–16, in Washington, DC. Presented in conjunction with the ACS Leadership Conference, the Advocacy Summit is an opportunity to rally surgery’s collective grassroots advocacy voice. More than 200 surgeons spent one day learning about such vital topics as reforming the Medicare physician payment system, protecting the surgical workforce, and funding graduate medical education (GME). Attendees also heard from advocacy and health care experts regarding how the current political climate affects Congress’ ability to pass legislation.
The meeting culminated on the second day of the summit with 186 surgeons heading to Capitol Hill to advocate for their profession by meeting with their representatives and senators. These surgeons have begun building relationships with key policymakers in Washington, which will serve surgeons and their patients well in the future.
Understanding the issues
Prior to attending the Summit, I felt a sense of hopelessness as if my hands were tied. I felt like a warrior fighting alone. Today, after hearing about the relevant issues, I feel like we are going to be able to fix things.
—Laura Schwartz, MD, FACS, pediatric neurosurgeon, New Jersey Pediatric Neurosurgical Associates, Hackensack, NJ
The nation’s health care system is undergoing a time of unprecedented change. There is enormous pressure to gain control of increasing health care costs, particularly as the baby boomers age and thereby increase the demand for services. The ACS Young Fellows Association (YFA) sponsored a panel at the Summit that discussed the future of health care. Moderated by Scott Coates, MD, FACS, Vice-Chair, YFA Member Services Work Group, the panel featured speakers Gail Wilensky, PhD, senior fellow, Project HOPE, Millwood, VA; Harold Miller, executive director, Center for Healthcare Quality and Payment Reform, Pittsburgh, PA; and Frank G. Opelka, MD, FACS, Associate Medical Director, ACS Division of Advocacy and Health Policy.
Dr. Wilensky, who is married to a physician, said she sympathizes with surgeons’ frustrations with the direction in which the health care system is moving. Dr. Wilensky discussed physician payments, the cost of health care, and spending—topics that have gained traction over the last several years. Spending “has gotten out of hand,” said Dr. Wilensky, and she is skeptical as to whether programs such as accountable care organizations (ACOs)—designed to provide more coordinated, high-quality care to Medicare patients—are the answer to physician payment woes. However, bundled payments that encourage efficiency could play a part in helping to lower health care costs, she said. Bundled payments cover services delivered by two or more providers during a single episode of care or over a specific period of time.*
Mr. Miller, however, said there is a “win-win-win” solution to accountable care that may benefit surgeons and patients while reducing Medicare spending. Under this model, health care professionals would choose to participate in a flexible, alternative payment and delivery model that best fits their practices and that delivers high-quality, efficient care.
He provided this example: In Lansing, MI, in 1987, an orthopaedic surgeon and Ingham Medical Center offered a fixed total price for surgical services for shoulder and knee problems. Included in the charge was a two-year warranty for subsequent services needed, such as repeat visits, imaging, re-hospitalization, and additional surgery. Using this approach, the health insurer paid 40 percent less than if the services had each been charged separately, the surgeon received more than 80 percent more in payment than otherwise, and the hospital received 13 percent more despite fewer re-hospitalizations. Mr. Miller attributed this result to the reduction in unnecessary auxiliary services such as radiography and physical therapy, in length of stay, and in complications and readmissions.
The College believes it has a solution as well, called the Value Based Update (VBU), noted Dr. Opelka.† The VBU calls for replacing the sustainable growth rate (SGR) formula used to calculate physician payment with a system that improves outcomes, quality, safety, and efficiency while reducing the growth in health care spending. Dr. Opelka explained how the VBU would work, highlighting that it would combine the College’s century of experience in quality measurement to improve patient care and reduce costs. This system shifts the emphasis from cost of care provided to the value of care provided, Dr. Opelka noted.
Atul Grover, MD, chief public policy officer, Association of American Medical Colleges, Washington, DC; Doug Henley, MD, chief executive officer, and executive vice president, American Academy of Family Physicians, Washington, DC; and Samuel Finlayson, MD, MPH, Kessler Director, Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA, discussed present and future physician workforce issues. The three presenters offered vastly different viewpoints. Among other topics, Dr. Grover discussed what drives physicians to choose certain specialties and practice locations, deficit reduction plans, and incentives for surgeons to practice in rural areas. Dr. Henley provided data on what he believes are probable causes of the current workforce shortage and suggested possible solutions, including appropriately valuing and compensating primary care physicians to address the income gap between primary care and other specialties and reforming GME. Dr. Finlayson, offering a different perspective, believes that increasing the number of surgeons is an “unwise response to the workforce crisis” and that “addressing geographic and specialty distribution is the main challenge.”†
As a leader on physician issues, the ACS seeks out partnerships with other critical stakeholders to encourage development of a fair payment system, address possible solutions to the workforce shortages, and advocate for medical liability reform and increased GME funding. Advocacy Summit attendees heard from three groups that have a significant stake in the health care system, including the business sector, insurers, and pharmaceutical and device manufacturers.
Maria Ghazal, vice-president and counsel of Business Roundtable, Washington, DC, an organization that represents the interests of many of the nation’s largest companies and employers, extended an invitation to work with the College on many issues, including the use of state insurance exchanges. Greg Gierer, vice-president of policy, America’s Health Insurance Plans, Washington, DC, agreed that collaborations through multi-stakeholder groups are effective in addressing elements of health care reform, particularly cost-containment. Mr. Gierer discussed health care cost and how insurers are leading changes in the marketplace through collaboration with providers and possible means of providing care to vulnerable populations through effective public-private cooperation. Lastly, Harlan F. Weisman, MD, chairman and chief executive officer of Coronado Biosciences, Inc., Burlington, MA, talked about the need to regain the country’s status as the world leader in the development of pharmaceutical research and advancement.
The price of politics
Bob Woodward, Pulitzer Prize-winning journalist for The Washington Post and author of The Price of Politics, opened the Summit on Sunday evening as the keynote dinner speaker. Mr. Woodward gave a behind-the-scenes look at government, politics, and the role of an investigative journalist. The book, based on 10 months of reporting, is a documented examination of how President Barack Obama and high-profile Republican and Democratic leaders in the U.S. Congress attempted to restore the American economy and improve the federal government’s fiscal condition.
He focused many of his comments on political investigative reporting, providing examples of events that have had a profound impact on today’s political climate, including President Bill Clinton’s impeachment, Vice-President Al Gore’s unsuccessful run for president, and President Obama’s fight to bring together both major parties in Congress. Mr. Woodward discussed his disappointment with the present-day media’s fact-finding methods, asking, “Why isn’t the media doing more?”
Reporters have turned to e-mails, Facebook, Twitter, and the like to find people to interview and to gather information, said Mr. Woodward. Widely regarded for his preeminent investigative reporting on the Watergate scandal that led to numerous government investigations and the resignation of President Richard Nixon, Mr. Woodward argued that reporters must get back to the basics. They must get in the field, investigate, and uncover the important stories. To fully understand and report on the key issues of the presidential and congressional campaigns, the state of the American economy, and how events transpire, a reporter must be in the trenches giving verbatim accounts of political events, meetings, and exchanges, Mr. Woodward said.
Mike Allen, chief White House correspondent for Politico and author of the Politico Playbook was the featured speaker at the Summit’s political luncheon. Mr. Allen is recognized for successfully using grassroots outreach to uncover political developments and engage the American people. Time magazine named Mr. Allen as having one of the top 140 Twitter feeds shaping the day’s debate.‡ His talk mostly centered on President Obama’s second election bid and how, unlike past U.S. presidents, the president’s reelection campaign was successful largely because of its effective use of technology-driven communications.
Regardless of a candidate’s political leanings, a campaign must be broad and optimistically open to change, explained Mr. Allen. He added that the Obama reelection campaign has proven the advantages of having a digital strategy and the confidence to explore the wide range of methods that appeal to various demographics. The Obama campaign used Facebook, Twitter, website advertising, video programs, and visits to neighborhoods, seeking out places such as local barbershops and beauty salons to engage voters.
Training to be an effective advocate
Christopher Kush, grassroots expert and chief executive officers of Soapbox Consulting, Washington, DC, sought to galvanize participants and help them navigate their day on Capitol Hill.
Congressional “Asks”: Medicare Physician Payment
House and Senate
- The ACS has drafted a proposal to reform the physician payment system using the VBU.
- The VBU focuses on delivering improved, high-quality care and resultant cost reductions. The ACS believes that its VBU proposal will produce shared savings across the delivery system that, when attributed appropriately, would allow for a stable baseline for all physicians without the need to cut payment rates.
- The critical component of the VBU is the Clinical Affinity Group (CAG), a team of physicians and providers who provide care for a specific condition, disease, or patient population. CAGs are the core of this proposal and might include categories such as cancer care, trauma care, surgery, cardiac care, frail elderly/end of life, digestive diseases, women’s health, rural and primary care/chronic care.
- Each CAG, which can be designed to account for regional variations in the provision of care to be captured and reflected in each physician’s reimbursements, will have its own patient-oriented, outcomes-based, risk-adjusted quality measures intended to foster continuous improvement and help lower costs.
The ACS submitted comments on the House Ways and Means and Energy and Commerce Committees’ joint SGR proposal:
- The ACS supports the permanent repeal of the SGR formula and a stable five-year period of statutory updates that would complement the development of new payment models needed to improve the quality of care and slow the growth in health care spending.
- The ACS is concerned that the application of budget neutrality to relative rankings will undermine overall reform efforts with tournament model reimbursement. Robbing Peter to pay Paul undercuts our combined goal of a more collaborative and coordinated health care delivery system.
- The ACS does not support an across-the-board cut to all physicians (10 to 15 percent) from the current baseline as a starting point in the period of stability. Presumably, only those providers deemed “top performers” would be eligible for incentive payments to recoup the 10 to 15 percent cut—in essence, a freeze at the current rate.
“Securing a legislative meeting is not always an easy task, and if you’re fortunate to get on the calendar [of a member of Congress], ensure that you are prepared,” said Mr. Kush, adding that it is “important to know the new members of Congress—who is on key committees for issues on which you advocate because those relationships help to get bills [introduced].”
“Hook, line, and sinker” is a three-phase method Mr. Kush suggests advocates use when meeting with a member of Congress. He says ultimately an advocate has three minutes for introductions (hook), five minutes to tell the story (line), and five minutes to make the request and discuss it (sinker).
In preparation for Lobby Day, participants were provided with individualized legislative meeting schedules, educational literature, and a pocket card that listed the critical health care talking points, or “Congressional Asks” (see sidebar).
Of particular interest was a limited-edition book, Inspiring Quality Tour: Lessons Learned in the Pursuit of Quality Surgical Health Care. Participants received their own copy of the book, and copies to present to policymakers on Lobby Day. The book can be accessed at www.facs.org/quality/lessonslearned.html.
“Advocating on Capitol Hill can be intimidating, and one hopes that in situations like this there’s someone to help show you the way—to help you understand the important issues. This meeting does that,” said Kyle Kalkwarf, MD, a Summit participant and resident at the University of Arkansas for Medical Science, Little Rock. Matthew Steliga, MD, FACS, agreed, stating, “The experience has been invaluable. The meeting has provided real information on how advocacy in action really works. I’m impressed.” Dr. Steliga is an assistant professor at the University of Arkansas for Medical Sciences in Little Rock, AR.
Grassroots and the ACSPA-SurgeonsPAC
In advance of Lobby Day, several members of Congress provided insight into issues on which they are searching for bipartisan solutions, such as medical liability reforms and reimbursement. Legislators who spoke included Reps. Kevin Brady (R-TX), Chair, House Ways and Means Health Subcommittee; Larry Bucshon, MD, FACS (R-IN); and Ami Bera, MD (D-CA).
“Get involved and stay involved,” was the collaborating message among many presenters. Jeff Carroll, chief of staff for Rep. Frank Pallone (D-NJ), gave a presentation titled Winning in Advocacy: Why Grassroots and Messaging Matter, in which he emphasized the influence political action committees (PACs), such as the American College of Surgeons Professional Association (ACSPA)-SurgeonsPAC, can have. “Access comes through PAC donations,” said Mr. Carroll. “It’s important to encourage members to give to the PAC. PAC donations help build trust and get you in the door to create effective relationships.”
Mr. Carroll also discussed the importance of grassroots efforts, and which methods work best, pointing out that “a lot of members of Congress pay attention to social media—and the College should, too.” Mr. Carroll added that face-to-face meetings will also continue to be an effective means of communicating messages to Congress. Meetings allow advocates to talk about issues that matter to them.
An essential part of the Summit was the opportunity for participants to meet and mingle with members of Congress. PAC contributors participated in a wine-tasting fundraiser and reception hosted by the ACSPA-SurgeonsPAC at the National Museum for Women in the Arts. Guests contributed more than $56,000 to the ACSPA-SurgeonsPAC at that event, which 11 members of Congress, many with medical backgrounds, attended:
- Rep. Dan Benishek, MD, FACS (R-MI)
- Rep. Diane Black, RN (R-TN)
- Rep. Michael Burgess, MD (R-TX)
- Rep. Lois Capps, RN (D-CA)
- Rep. Phil Gingrey, MD (R-GA)
- Rep. Andy Harris, MD (R-MD)
- Rep. Joe Heck, MD (R-NV)
- Sen. Johnny Isakson (R-GA)
- Rep. Leonard Lance (R-NJ)
- Rep. Phil Roe, MD (R-TN)
- Rep. Tom Price, MD, FACS (R-GA)
The 2014 Leadership Conference and Advocacy Summit will take place March 29–April 1 in Washington, DC.
*To better understand bundled payment options, the ACS released The Surgeons and Bundled Payment Models: A Primer for Understanding Alternative Physician Payment Approaches at the Summit. This resource summarizes the concept of bundled payment and the effect bundled payment policies could have on surgical practices. To access the primer, go to the Members-only website, http://efacs.org/portal/page/portal/ACS_Content/Advocacy.
†An overview of the ACS VBU project can be accessed using the following link, http://www.facs.org/ahp/news/2013/may.html#Summit_Overview.
‡The 140 Best Twitter Feeds of 2011: Mike Allen. http://www.time.com/time/specials/packages/article/0,28804,2058946_2059032_2059024,00.html.