Report on ACSPA/ACS activities: June 2013

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American College of Surgeons Professional Association (ACSPA)

Through June 2013, the American College of Surgeons Professional Association’s political action committee (ACSPA-SurgeonsPAC) has raised $275,000 (including personal and corporate contributions) from 875 College members and staff, with an average contribution of $314. Of this amount, $237,413.32 represent personal (hard) dollars and $37,320 are corporate (soft) dollars. So far in the 2014 election cycle, the PAC has contributed $146,000 to 37 candidates, leadership PACs, and party committees. Of this amount, 56 percent was given to Republicans and 44 percent to Democrats.

The ACSPA-SurgeonsPAC and 26 physician groups cohosted meetings with the Republican and Democrat freshman classes in February and March, respectively. The meetings provided opportunities to establish connections with new members of Congress and to foster new surgical champions.

The PAC also hosted a number of events at the 2012 Advocacy Summit, April 14–16, in Washington, DC. The political luncheon, presented April 15, featured Mike Allen, Politico reporter and author of the Politico Playbook. Mr. Allen, who offered an insider’s look at DC politics and the life of a political reporter, answered audience questions on specific upcoming races and previewed the political landscape for the 2016 presidential race. Later that evening, the PAC hosted a wine-tasting fundraiser at the National Museum for Women in the Arts. A total of 11 members of Congress, most with medical backgrounds, joined the attendees for the evening reception, which helped the ACSPA-SurgeonsPAC raise more than $56,000.

American College of Surgeons (ACS)

Member Services

A number of significant advances will enable the Board of Governors (B/G) to serve as a more vital and active component of the College. One of the B/G’s Executive Committee’s major goals this past year was to review and revise the Governors’ responsibilities to be fully aligned with ACS goals. Currently, 270 individuals serve on the ACS B/G, including 149 Governors-at-Large representing each U.S. state and Canadian province, 81 specialty Governors representing surgical associations and societies, and 40 Governors who represent countries and chapters internationally. The B/G serves as a liaison between the Board of Regents and the Fellows and as a clearinghouse for the Regents on assigned subjects and local problems.

Specific responsibilities under the new paradigm are listed in the sidebar.

The B/G Committees have been reorganized to complement the divisions—or pillars—of the American College of Surgeons. The five pillars consist of:

• Member Services
• Education
• Advocacy and Health Policy
• Quality, Research, and Optimal Care
• Communications

Each new pillar is designed to better engage the individual Governors in areas that are most compatible with their own interests and talents, to reduce duplication of work, and to better serve the ACS mission and goals. The B/G Executive Committee is finalizing the implementation of the five pillars, and Executive Committee members will serve as Pillar Leads. Each pillar contains relevant workgroups, and each Governor is asked to serve on at least one workgroup.

The new structure is illustrated in the sidebar.

In addition, the Board of Governors will retain the B/G Fiscal Affairs Committee, which is responsible for monitoring and providing Governor input to ACS leadership on matters of dues and finance. The B/G Secretary (currently William G. Cioffi, Jr., MD, FACS) will serve as the Chair of this Committee.

Advocacy

The ACS recently released the Surgeons and Bundled Payment Models: A Primer for Understanding Alternative Physician Payment Approaches, which summarizes the concept of bundled payment and its potential effect on surgical practices. Given the increased focus on bundling as an approach to payment reform, the ACS General Surgery Coding and Reimbursement Committee formed a workgroup to develop a process for creating clinically coherent bundled payment models and analyzing the possible opportunities and barriers. The workgroup was composed of surgeon experts in quality and coding and reimbursement, and was tasked with:

• Determining the resources and expertise necessary for developing clinically coherent surgical bundles
• Developing general principles regarding the selection, optimal structure, and function of surgical bundles
• Providing robust guidelines about which procedures or condition characteristics must be present to construct a usable bundle
• Providing insight about which characteristics might make a procedure or condition a poor candidate for bundled payment

The primer also provides an overview of existing bundled payment programs at Geisinger Health System in Pennsylvania and BlueCross BlueShield of Massachusetts, as well as common issues to consider when developing a bundle. To access this members-only resource, go to www.efacs.org, and enter your ACS-issued username and password.

On April 26, the Centers for Medicare & Medicaid Services (CMS) released the fiscal year (FY) 2014 Inpatient Prospective Payment System proposed rule, which calls for increasing average inpatient payments by 0.8 percent in FY 2014, which begins October 1, 2013. This update is contingent on hospitals reporting specified quality data set forth in the Inpatient Quality Reporting Program.

The proposed rule also would reduce the disproportionate share of hospital payments to 25 percent of the amount that Medicare currently pays. The remaining 75 percent would be distributed to hospitals based on their share of uncompensated care for Medicare patients. The proposed rule also makes a number of quality-related changes, including an increase from the current 1 percent to 2 percent in the amount of Medicare payments that hospitals would lose based on excessive readmissions under the Hospital Readmissions Reduction Program; an increase in the percent reduction of hospital Medicare payments to fund the Hospital Value-Based Purchasing Program from the current 1 percent to 1.25 percent; and reducing Medicare payments by 1 percent for hospitals that are in the highest quartile with respect to their rates of Hospital-Acquired Conditions.

Another significant proposal would revise the definition of inpatient. The new definition would presume that hospital inpatient admissions of more than one Medicare utilization day (defined by crossing two midnights) in the hospital are appropriate for Medicare patients receiving medically necessary services.

ACS staff is evaluating these and other elements of the proposed rule to determine their impact on surgery and will submit a comment letter to CMS. Read a copy of the proposed rule. Read fact sheets on the payment and quality aspects of the proposed rule.

The “fiscal cliff” legislation that Congress passed January 1, 2013, postponed the 27 percent cut in Medicare reimbursement that was scheduled to take effect in January and froze payment at current rates through December 31, 2013. The ACS continues to lead the physician charge to eliminate the sustainable growth rate (SGR) formula. The ACS spent much of 2012 lobbying for physician payment reform, urging Congress to address the long-term implications of a broken physician payment system and its incompatibility with the provision of care. The ACS continues to urge Congress to find the political will to pass permanent repeal legislation and better serve American patients.

Efforts in the 112th Congress have helped to establish the ACS as one of the leading organizations at the table in discussions on proposals to repeal and replace the SGR. The ACS is one of the only physician organizations that testified before the three key congressional committees that have jurisdiction over the SGR: the Senate Finance, the House Energy and Commerce, and the House Ways and Means Committees. At these hearings and in ongoing meetings with members of Congress and congressional staff on Medicare physician payment reform proposals, College leaders have discussed the organization’s Value-Based Update (VBU) framework for reform.

Furthermore, the ACS has commented on drafts of a joint proposal on Medicare physician payment reform put forth by the House Ways and Means and Energy and Commerce Committees. As a first step in the reform process, the joint proposal would eliminate the SGR, a move that the College has long supported. The next step would provide a period of stability, followed by a phase-in of changes to the payment system. The College offered recommendations on how the VBU concept could be applied as the joint proposal moves forward. The ACS has also expressed concerns with some of the concepts in the joint proposal and will continue to work closely with the committees as the plan is further developed.

The congressional Super Committee’s failure to reach a deal to cut spending last year resulted in automatic sequestration of billions of dollars in both defense and domestic spending, including Medicare. As a result, Medicare physician and graduate medical education payments were cut 2 percent beginning in March. The Medicare portion of these mandated cuts is expected to reduce Medicare reimbursements to physicians by 2 percent as well as a 2 percent cut to graduate medical education. Sequestration also has had a major effect on medical research. It is estimated that funding for the National Institutes of Health (NIH) will be reduced by as much as $2.4 billion (8 percent) next year, forcing the NIH to eliminate as many as 2,300 grants. The ACS has been working to increase awareness of this issue and will continue to discuss the health care-related cuts during meetings with legislators and congressional staff.

A provision of H.R. 8, the legislation that averted the fiscal cliff at the end of 2012, would allow physicians to meet Physician Quality Reporting System (PQRS) requirements through participation in specialty registries. The ACS was one of a few groups to lead this effort, which could encourage more hospitals to participate in the College’s National Surgical Quality Improvement Program (ACS NSQIP^®). The provision would essentially grant the Secretary of the Department of Health and Human Services the authority to deem eligible physicians as having satisfactorily submitted data on quality measures for purposes of PQRS if they participate in a qualified clinical data registry beginning in 2014.

In April, the ACS responded to a CMS request for information on the use of Clinical Quality Measures (CQMs) reported under the PQRS and Electronic Health Record (EHR) Incentive Program as outlined in the Tax Payer Relief Act. These provisions were included in the law because of programs’ inflexibility and low participation rates. The letter indicates ACS support of the expanded use of specialty registries in these programs because measures from these registries are typically more relevant, clinically appropriate, and actionable for surgeons. By allowing surgeons to participate through a source developed and run by surgeons, surgeon participation in reporting CQMs to CMS will likely increase. The College noted that the ACS has five quality registries: the Surgeon-Specific Registry, ACS NSQIP, Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program, National Cancer Data Base, and the Trauma Quality Improvement Program.

In February 2012, the ACS sent a letter to CMS in response to a request for public comment on whether CMS should change the national coverage decision (NCD) facility certification requirement for bariatric surgery for the treatment of morbid obesity. CMS solicited responses questioning whether accreditation should continue to be required for Medicare reimbursement. The NCD covers bariatric surgery procedures that the ACS or the American Society of Metabolic and Bariatric Surgeons have accredited in order to promote continuous quality improvement and patient safety. The ACS letter supported the continuation of the NCD certification requirement because it contributes to the advancement of quality and safety in bariatric surgical procedures.

In March, Rep. Diane Black (R-TN) reintroduced legislation to address a number of concerns with the current EHR incentive program. The bill, H.R. 1131, the Electronic Health Record Improvement Act would, among other things: create a hardship exemption from penalties for small practices and physicians in and near retirement to avoid workforce shortages, shorten the gap between the performance period and the application of the penalty, expand options for participation in the incentive program, improve quality measures by using specialty-led registries, and establish an appeals process before application of penalties. Twenty-one other medical organizations joined the ACS in sending a letter of support for the legislation in March. The ACS continues to seek enactment of the legislation.

Education

The 2013 ACS Clinical Congress will take place October 6–10, in Washington, DC. The Clinical Congress program is being continually transformed to address the evolving learning needs of surgeons and members of surgical teams. This year’s program addresses a range of important clinical and non-clinical topics and includes the requisite balance between review sessions and presentations of original scientific work. The program is organized into tracks that are composed of blocks and include various sessions and postgraduate courses.

In addition to opportunities to earn Category 1 continuing medical education (CME) credits, attendees may earn other CME credits for patient safety, trauma and critical care, ethics, and palliative care. In 2013, Special Certificates for Self-Assessment Credits earned will be awarded for designated sessions and postgraduate courses.

The final 2013 Clinical Congress program is composed of 25 tracks and includes 11 Named Lectures, 102 Panel Sessions, and 28 Didactic and Skills Postgraduate Courses. A new track for rural surgery has been added, along with a special Centennial track. Two new sessions, “Ten Hot Topics in General Surgery” and “What’s New in Advocacy and Health Policy: Top Ten Advances in the Past Year,” will take place October 10. The abstract-driven Scientific Sessions include Scientific Papers, Poster Presentations, presentations in the Owen H. Wangensteen Surgical Forum Sessions, Video-based Education Sessions, and Meet-the-Expert Luncheons. In addition, several Town Hall Meetings will convene. Approximately 1,700 speakers and faculty will participate in the 2013 Clinical Congress Program.

Several new Didactic and Skills Postgraduate Courses have been included. Postgraduate courses designed to address critical needs in the changing health care environment are listed below:

• Measure Twice, Cut Once! Optimizing Surgical Systems of Care
• MOC Review: Essentials for Surgical Specialties
• Non-Technical Skills for Surgeons (NOTSS) in the Operating Room
• Behaviors in High-Performing Teams

Additional new Postgraduate Courses aimed at addressing vital topics:

• Minimally Invasive Colorectal Surgery Skills Course
• Ultrasound for Pediatric Surgeons
• Emergency Airways

Each Postgraduate Course of the 2013 Clinical Congress will offer the opportunity to earn a special Certificate of Verification based on the Division of Education’s Five-Level Verification Program. Of the Didactic Postgraduate Courses, eight will offer Level I Verification, and five will offer Level II Verification. Of the Skills Courses, two will offer Level I Verification, 10 will offer Level II Verification, and three will offer Level III Verification.

Awards will be presented for the best scientific submissions to the 2013 Clinical Congress Program. These will include 15 awards for the best abstracts submitted for the Surgical Forum. Posters of Exceptional Merit will be presented by the authors on Tuesday during the lunch break, and one will be recognized as the Best Scientific Poster.

The 2013 Clinical Congress will be supported by an enhanced Clinical Congress smartphone app, which will make it easier for attendees to manage their schedules and programs. The College is working to replace the traditional paper evaluations with electronic evaluations for Clinical Congress sessions. Thirty-five sessions have been selected for webcasting.

Surgical Education and Self-Assessment Program (SESAP^®) 15 is scheduled for release at the 2013 Clinical Congress and will feature more content and questions than before. More than 825 questions and critiques will be available. Up to 90 Category 1 CME Self-Assessment Credits™ will be available and for the first time, learners will be able to claim credits after they complete each category listed in the sidebar.

Additional SESAP products are SESAP Sampler and SESAP Audio Companion, a home study program that helps surgeons maintain knowledge of clinical surgery.

SESAP Sampler is a Web-based resource consisting of monthly modules designed to enhance surgical decision making and patient care through ongoing self-assessment and review of surgical content. This product includes previously unpublished SESAP 14 questions and is available through an annual subscription. It provides the opportunity to earn six Category 1 CME credits annually. As of March 31, SESAP Sampler had 170 subscribers. Unpublished questions from SESAP 15 will be added beginning in October.

Fundamentals of Laparoscopic Surgery (FLS™) is a collaborative program between the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and the College that has had a significant effect on resident education. The grant that supports dissemination and implementation of this program is coming to a close. In February 2012, the Executive Committee of the ACS Board of Regents approved publication of a Joint Statement with SAGES that recommends that all surgeons practicing laparoscopic surgery be certified through the FLS program and the institutions credentialing surgeons to perform laparoscopic surgery consider FLS certification as a requirement in their credentialing process.

The ACS Practice Guidelines Program is designed to produce concise, focused modules containing practice guidelines. The modules present the parts of the guidelines that are pertinent to the practice of general surgery. Guidelines are chosen based on diagnoses that are relevant to the 20 operations that general surgeons most frequently perform. The modules consist of six to eight pages of information, including the source of the guidelines, an analysis of the strength of the evidence supporting the recommendations, a flow diagram of a typical patient, a page summarizing the resources necessary to implement the guidelines in a surgeon’s practice, and a listing of the data necessary to determine if the guideline is working appropriately in practice. Each module concludes with a list of recommended articles for additional information. The modules are intended to be used at the point-of-care and may be accessed through an electronic device.

Development of guidelines involves a multi-step process. Once a preliminary draft of a module has been completed, the ACS Board of Governors Best Practices Workgroup reviews the module. Suggested changes are incorporated, and the module is sent to a group of experts appointed by the Chair of the Advisory Council for General Surgery for final approval. The module is then formatted for online use.

Much progress has been made in the ACS Practice Guidelines Program over the past year. A manager has been recruited, an initial group of guidelines has been identified, and the first module, covering the management of differentiated thyroid cancer, has been completed. The ACS also has identified a vendor that will develop the distribution system for the modules. The first set of modules will be introduced at the 2013 Clinical Congress.

The Accreditation Council for Continuing Medical Education has approved the ACS to provide Category 1 CME credits for educational programs. The ACS also participates in a joint sponsorship program that provides CME credits to individuals participating in educational programs of other surgical organizations. In calendar year 2012, ACS accredited a total of 1,844 activities and provided more than 24,000 credits to more than 140,000 physicians. These activities included a variety of learning formats such as live conferences and courses, Internet-based activities, and journal-based CME. The Joint Sponsorship Program provides other surgical societies the opportunity to offer CME credits for their educational conferences and meetings; 140 applied for credits in 2012.

Journal of the American College of Surgeons (JACS)

From 2008 to 2012 the number of original scientific manuscripts submitted to JACS increased by 66 percent, in part because JACS now publishes papers presented at two surgical society meetings—the Southern Surgical Association and the Western Surgical Association. The increase in high-quality original scientific articles will continue with the addition of papers submitted from the New England Surgical Society meeting this fall. So far in 2013, JACS articles have been covered in diverse media ranging from US News &World Report and Medical News Today to the Harvard Gazette, and in articles distributed by UPI and Reuters news services.

The popular JACS app, free to Fellows and subscribers, offers a convenient way to read the full text of JACS articles. In the year since it was launched, the number of users has steadily increased. In May 2013, the JACS website had 8,609 visits through the app. In the first four months of 2013, JACS provided 26,666 CME credits to 1,977 individuals, averaging about 13.5 credits per person.

The JACS CME mobile-friendly website has recently launched. It was developed by the College’s Information Technology (IT) staff and allows Fellows and subscribers to take the tests for CME credit using their smartphones and iPads. The ACS anticipates the number of Fellows and subscribers who get their CME credits through JACS will increase because of this innovation.

JACS has initiated a new online feature, “In Press Accepted Manuscripts,” through which accepted manuscripts are now published online approximately one-and-a-half weeks after acceptance, adding greater visibility with early publication.

ACS Information Technology (IT)

The College is a complex organization with a diverse set of programs and services. The IT infrastructure to support these programs contains more than 30 software applications including:

• Membership management
• E-commerce
• Accreditation/verification management (cancer, breast, trauma, bariatric, education)
• Trauma course management
• Abstract and speaker management
• Online CME

These programs are migrating to a single constituent management platform, which allows the College to share common data about members and institutions across the various programs.

Benefits of this approach include:

• When a constituent updates their data, such as contact information, it will be available across all programs
• The single member profile will allow the College to personalize communications based on a member’s interests
• The College will have a better view of institutional participation across its programs
• There will be economy of scale in internal software development and maintenance

The use of mobile devices among members is growing rapidly. The College is in the process of updating its Web presence to support access on mobile devices. Two technical alternatives are available to accomplish this goal—one is to develop mobile apps, the other is to develop mobile-friendly Web pages. The ACS is leaning toward initial development of mobile-friendly Web pages, where possible.

The College has hired a consultant to assist the College in developing an IT strategy for the coming years. The scope includes a review of IT needs across the College.

ACS Centennial

A number of activities related to the College’s Centennial celebration will take place at the 2013 Clinical Congress.

• Flags will be flown over the Capitol building in honor of the Centennial, and one will be presented to the Board of Regents for permanent placement at ACS headquarters.
• Centennial banners will be displayed at convention hotels, on shuttle buses, at the convention center, and at 20 F Street.
• Plans are under way to display a permanent street banner in front of the Chicago headquarters building.
• A military choir has been invited to perform the Canadian and U.S. national anthems at the Opening Ceremony.
• Ads and features about the Centennial on Shuttle Vision (buses) during the Clinical Congress will continue.
• An updated timeline, website, display, and video focusing on 100 years of the ACS juxtaposed with a century of major world events and accomplishments will be displayed at the convention center.
• There will be ongoing participation by and recognition of our major exhibitor partners.
• Special “100 Years” logo will continue to be featured on College materials, including all publications, badges, signage, podiums, social invitations, menus, flyers, and letterheads.
• The celebratory reception following the Convocation at the Clinical Congress, along with a cake-cutting event on Tuesday evening after the Board of Governors Dinner, will be repeated.
• Commemorative champagne flutes will be available for toasts at luncheons, receptions, dinners, and special Centennial events.
• Continue featuring the Centennial in the Bulletin and on the website throughout the year and in the 2013 Clinical Congress News.
• Distinctive and targeted gifts will be presented to leadership, all Clinical Congress attendees, and staff, and once again the new Fellows will receive a special lapel pin with the “100 Years” logo.
• College staff are currently submitting their comments for the College’s internal publication (The Saint Clairion) on what is means to work for the College as it celebrates its 100-year birthday. Staff will also sign a giant birthday card.