Applying advocacy skills: Gaining influence from the statehouse to Capitol Hill

Docere, meaning “to teach,” is the Latin origin of the word doctor.¹ Advocacy means the act or process of supporting a cause or proposal.² In other words, an advocate is someone who educates interested parties—frequently lawmakers—about a topic. Therefore, serving as a physician advocate is an extension of what most surgeons already do as a part of their responsibilities to teach and lead.³ Within their daily practices, surgeons teach their patients, patient families, residents, students, nurses, other physicians, and a multitude of other stakeholders. Advocacy is a continuation of those same concepts to a group not directly involved in patient care.

To be an advocate, a surgeon must make her or his opinions or preferences known to lawmakers and policymakers through some form of communication, be it written, verbal, or by attendance at an event. Often the advocate’s perspective may match the expected and generally accepted position of the population majority. However, their perspective also could draw dissension and present a need to create or offer an alternative solution. Such a position can expose an individual’s or an organization’s vulnerabilities, drawing sometimes unwanted attention. Socially and professionally, the path of least resistance often is to steer clear of conflict by focusing on clinical and professional concerns and challenges that face individual patients at the local level. As a result, surgeon advocates traditionally have focused on the science of medicine and clinical application as it applies to their individual practice, patient population, or the local hospital environment.

Increasing interest in federal advocacy

In recent years, however, North American medical and surgical organizations have sought to think of the physician advocate role more broadly. The Royal College of Physicians and Surgeons of Canada (RCPSC), for example, has developed the CanMEDS Physician Competency Framework, which includes health advocate among one of seven roles needed to be better physicians.^4,5 In the U.S., the Accreditation Council for Graduate Medical Education (ACGME) Pediatrics Residency Review Committee (P-RRC) now requires training programs to provide advocacy training and experience to all pediatric residents, and the American Medical Association has been a longtime advocate for both patients and physicians in Washington, DC.^3,6

The American College of Surgeons (ACS) has developed a reputation as an increasingly influential leader in surgical advocacy. This is highlighted by the important role that the ACS played in the passage of legislation in 2015 that repealed the broken sustainable growth rate (SGR) formula used to calculate Medicare physician payments. The ACS Division of Advocacy and Health Policy (DAHP) maintains strong relationships with state and federal legislative and regulatory leaders and is a resource for Fellows seeking to engage in advocacy.

Traditionally, health policy advocacy has focused on policies that affect the delivery of care for specific medical conditions, such as amyotrophic lateral sclerosis or renal failure, rather than advocating for broad legislation that protects patients on a macro scale or that provides a framework for systematic approaches to patient care. This approach has changed as health care costs have risen and federal legislation and regulations have played an expanding role in health care delivery.

Indeed, many of the intricacies of health care delivery are affected by policy, politics, and bureaucracy. Consequently, myriad stakeholders participate in the health care delivery system, including device manufacturers, pharmaceutical companies, insurance companies, and privately run health care organizations. Each group has built relationships in Washington and in state capitals to ensure that lawmakers hear their viewpoints. The surgeon is best suited to educate decision makers on the needs of surgical patients and the surgical profession.

Because a primary focus of the government is the development and management of the federal budget, many policymakers are concerned about the impact of health care spending. Physicians generate significant economic output—each U.S. physician supports an average of $2.2 million in economic output for a total of $1.6 trillion nationwide yearly, and physicians support 10 million jobs nationwide that provide $775 billion in wages annually.⁷ As these figures indicate, physicians have a substantial impact on the national economy, which positions surgeons to have considerable influence with lawmakers.

The relevance of surgeon leadership

As David B. Hoyt, MD, FACS, ACS Executive Director, said at the 2015 Leadership & Advocacy Summit, “Physicians, I would argue, are natural leaders, and creativity is the most desirable leadership attribute.”⁸ Surgeons lead in the operating room, in the clinic, in the boardroom, and in the community. They have the courage to approach one of the most sacred depths of the universe, the human body, in an attempt to restore health or quality of life in a direct and physical manner. They have the dedication to complete a long and arduous education and training process. They are masters of both immediate results and delayed gratification. Policy change is a formidable opponent, as are cancer, inflammation, immunosuppression, and countless other barriers to the clinical management of patients. Yet, these challenges are met head-on by the well-trained professional surgeon.

Health care’s involvement in governmental regulation is not new. The evolution of modern medicine came with rising costs and society’s commitment to provide for those Americans who could not provide for themselves, namely seniors. In 1965, President Lyndon B. Johnson signed legislation that established Medicare under the Social Security Act, providing health insurance to individuals ages 65 and older.⁹ At the time, senior citizens were paying up to three times what younger Americans paid for health insurance, and 35 percent of older Americans were unable to afford health insurance coverage at all.¹⁰ Medicare coverage has gradually expanded due to a growing elderly population, increased life expectancy, and broader scope of coverage, which now includes rehabilitative care, dialysis, prescription drugs, and hospice services.¹⁰

Health care organizations, like other advocacy groups, must play an active role not only in resolving crises, but also in the day-to-day decisions that will affect patient care.¹¹ For effective and sustained advocacy to take root, surgeons must cultivate personal relationships with their lawmakers.

Grassroots advocacy

Legislative advocates often refer to advocacy efforts with the sometimes nebulous “grassroots” label. Typically a grassroots campaign is an organized effort to influence or raise awareness about a particular cause or issue at its base, which may be at the local, state, regional, or national level. Regardless of the level at which a policy issue is being addressed, grassroots advocacy refers to individuals communicating directly with the appropriate elected official. Due to a rising number of health care issues that transcend compartmentalization, physician advocates must be active across the entire policymaking spectrum.³

It is worth noting that political advancement typically follows a hierarchical model. Most often politicians start their career at a lower elected level—such as on city council or the school board—and then progressively ascend the political ladder, perhaps moving into a county-level position, followed by serving in the state government, and ultimately moving on to federal office. With this typical career ascension, it makes sense to build relationships with politicians early in their career, when they are likely to be more accessible. If that opportunity is not available, it is important to develop relationships with politicians who are already in elected positions, as it is their responsibility to represent the interests and concerns of their constituents.

Surgeons are uniquely positioned to build relationships with lawmakers because of the high regard in which they are held in their local communities. Lawmakers respect surgeons and their expertise on health-related issues. In general, very few Americans are involved in the political process. Only 1 percent of the general public is actively involved in political activities, such as fundraising or volunteering in a campaign.¹² Surgeons, therefore, can hold additional influence with lawmakers through their increased engagement in the political process combined with their professional influence.⁴

The ascension of power

Although it is optimal to foster relationships and get acquainted with political leaders early in their careers, this approach has an inherent problem—no one can predict which elected officials will hold positions of particular strength or influence in the future. Development of relationships at this earlier stage may pay off later as specific lawmakers ascend the political ladder. Following are examples of two congressional leaders who followed different paths to their current positions, but each provided an opportunity for relationship building with surgical constituents.

Speaker of the U.S. House of Representatives Paul Ryan (R-WI) was originally elected to Congress without holding any previous office. Speaker Ryan was, however, a respected and involved member of his community and remains an ardent supporter of his local constituency. Speaker Ryan was elected to represent Wisconsin’s 1st District in the House in 1999 after the incumbent stepped down to make an unsuccessful bid for the U.S. Senate. He quickly became a respected member among his peers and was nominated to the House Committee on the Budget, which he chaired for two years (2013–2015). In 2015, he became chairman of the powerful Committee on Ways and Means and a member of its Health Subcommittee. This committee holds great influence, as it is the main author of legislation relating to taxes and payments for health care, health delivery systems, and health research.¹³ Speaker Ryan’s tenure in the House has provided ample time for a constituent to build a relationship. When in his district, Speaker Ryan focuses primarily on his family and his constituents. However, he also supports a broader audience via speaking sessions and forums.

In an effort to broaden my own grassroots experience, I participated in a forum held for Representative Ryan, then-Chairman of Ways and Means. The forum was small enough that I was able to interact with the congressman and to make a personal connection discussing bow hunting and personal fitness. A roundtable question-and-answer session followed, allowing for direct policy-level discussion. At the roundtable, Representative Ryan recognized me as the only surgeon in the room of physicians. Topics discussed on this occasion included repeal of the SGR, during which the congressman acknowledged the important role that the ACS played in achieving its elimination.

Another topic addressed at the forum was that of the quality and safety metrics outlined in the new Merit-based Incentive Payment System (MIPS) created by the Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act of 2015. Because most members of Congress are in professions other than medicine, it is the responsibility of physicians, particularly surgeons, to help them develop meaningful metrics applicable to surgical practice.

It was helpful to have raw insight into the inner workings of Congress. This experience showed me that members of Congress value knowledge and input from subject matter experts. If surgeons fail to fill the vacuum of knowledge and experience about patient care on Capitol Hill, other stakeholders will fill that void, and we and our patients will suffer the consequences. Now is the optimal time and opportunity for surgeons to share their expertise and educate their lawmakers in a way that will have a meaningful and lasting influence.

Rep. Tom Price, MD, FACS (R-GA), has been directly involved in politics for a longer period. Congressman Price has represented Georgia’s sixth district since 2005. Previously, he served in the Georgia Senate, starting in 1997, until he won his current seat in the U.S. House of Representatives. Representative Price has been a strong advocate for health care, and surgical care in particular. For example, he was instrumental in the repeal of the SGR and in stopping the Centers for Medicare & Medicaid Services’ (CMS) plan to turn all 30- and 90-day global surgical codes into 0-day codes. Most recently, he was instrumental in the passage of legislation providing physicians with a blanket exception from Stage 2 requirements in CMS’ electronic health record meaningful use program (see related article). Representative Price’s participation offers a novel example of surgeon involvement in governing and provides a framework with which to understand and develop relationships in advocacy.¹¹

Relationship building

It is imperative to develop relationships with lawmakers at the local, state, and federal levels, as they may be looking for an expert health care advisor. For surgeons in active practice, relationship building can seem like one more activity competing for their finite time. However, with the changing landscape of the economy and the building of new health care bureaucracies to regulate ever-expanding care options and treatment, every Fellow must make the time to serve as a surgeon advocate.

Involvement in advocacy does not need to be overwhelming or excessively time-consuming. In addition to building relationships with lawmakers, surgeons can help to influence the legislative process by contributing directly to the campaigns of candidates who support surgery’s legislative agenda or who support the efforts of organized medicine.

The ACS can help

The College offers several ways for Fellows to get involved with grassroots advocacy at the state and federal levels. First, the Leadership & Advocacy Summit is an efficient way to learn about federal health care issues and techniques to engage your personal legislators. (See sidebar for information about the 2016 Leadership & Advocacy Summit.)

The ACS Chapter Lobby Day Grant Program offers Fellows an opportunity to expand advocacy efforts at the state level. More than 20 chapters have hosted a state lobby day since the program’s inception in 2010. (See sidebar, below, for more information.)

Another way to engage with legislators is to arrange, either individually or with the assistance of ACS staff, participation in in-district meetings. When legislators are in their home districts, they are often more accessible than when Congress is in session. Surgeon advocates might also consider attending or hosting a fund-raising event.

E-mails and phone calls are another important way to inform lawmakers about a surgery-related topic.

A valuable tool that the College offers is SurgeonsVoice. This website provides direct communication with your legislators’ offices, summaries of current legislative issues, and a portal to the ACS Professional Association Political Action Committee (ACSPA-SurgeonsPAC). Simply log on with your ACS ID and last name to access these tools.

Advocacy encompasses many possibilities and activities. To be an advocate, one need not be a spokesperson or policy leader. Your role can range from writing a letter to your member of Congress, to attending the Leadership & Advocacy Summit, or to meeting with lawmakers while they are in their district offices. What matters is that you find a way to be involved—as a teacher and as a leader.

 

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References

1. Docere. Wikipedia. Available at: https://en.wikipedia.org/wiki/Docere. Accessed January 20, 2016.
2. Advocacy. Merriam-Webster.com. Available at: www.merriam-webster.com/dictionary/Advocacy. Accessed January 7, 2016.
3. Earnest MA, Wong SL, Federico SG. Perspective: Physician advocacy: What is it and how do we do it? Acad Med. 2010;81(1):63-67.
4. Royal College of Physicians and Surgeons of Canada. Health advocate definition and description. Available at: www.royalcollege.ca/portal/page/portal/rc/canmeds/framework/health_advocate. Accessed January 7, 2016.
5. Shaw D. Advocacy: The role of health professional associations. Int J Gynaecol Obstet. 2014;127(S1):S43-S48.
6. The American Board of Pediatrics. The Pediatrics Milestone Project. Available at: www.acgme.org/acgmeweb/Portals/0/PDFs/Milestones/PediatricsMilestones.pdf. Accessed January 8, 2016.
7. American Medical Association. AMA economic impact study. Available at: www.ama-assn.org/ama/pub/advocacy/state-advocacy-arc.page. Accessed January 18, 2016.
8. Hughes KA. Why are you here? To lead, to advocate, and to connect. Bull Am Coll Surg. 2015;100(7):80-82. Available at: bulletin.facs.org/2015/07/a-fellows-perspective-on-the-summit-why-are-you-here-to-lead-to-advocate-and-to-connect/. Accessed January 29, 2016.
9. Centers for Medicare & Medicaid Services. CMS’ program history. Available at: www.cms.gov/About-CMS/Agency-Information/History/index.html?redirect=/History/. Accessed January 7, 2016.
10. Medicare (United States). Wikipedia. Available at: https://en.wikipedia.org/wiki/Medicare_%28United_States%29. Accessed January 7, 2016.
11. Mackenbach JP. Politics is nothing but medicine at a larger scale: Reflections on public health’s biggest idea. J Epidemiol Community Health. 2009;63(3):181-184.
12. Sethi MK, Obremskey A, Sathiyakumar V, Gill JT, Mather III RC. The evolution of advocacy and orthopaedic surgery. Clin Orthop Relat Res. 2013;471(6):1873-1878.
13. U.S. House of Representatives Committee on Ways and Means. Health Subcommittee. Available at: http://waysandmeans.house.gov/subcommittee/health. Accessed December 18, 2015.