From fundamental changes in the physician-patient relationship to the evolving role of technology, nearly every aspect of surgery has undergone a transformation in recent decades. Yet one constant of surgical practice has been the role of tradition, whereby each generation of surgeons has guided and shaped the next.1
A vital part of the tradition of surgery is advocating on behalf of the surgical patient.2-6 The annals of the American College of Surgeons (ACS) are replete with examples of physician advocacy spearheaded by both nationally prominent surgeons and local advocates. Contemporary leaders continue to reimagine and reinvent this tradition, but the essence of advocacy remains unchanged: sustained, engaged, grassroots efforts at the national and state level to protect our patients and our profession.7,8
These efforts have included advocacy for improved access to care, payment and liability reforms, and improvement in the quality of care and outcomes for the surgical patient. The ACS Professional Association political action committee (ACSPA-SurgeonsPAC) was established in 2002 to give surgeons a more powerful voice in the state and federal legislatures. In 2014, the ACS launched SurgeonsVoice, an online platform for surgeons to communicate with policymakers on the issues that matter most to their practices.9 In addition, the annual ACS Leadership & Advocacy Summit connects hundreds of surgeon advocates in person who share key issues with lawmakers on Capitol Hill.10,11 These efforts, among many others, have sustained successful policy campaigns, including an effort that led to the passage of the Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act (MACRA) of 2015, which resulted in the repeal of the sustainable growth rate (SGR) formula used to calculate Medicare physician payment.12-14
Through the Resident and Associate Society of the ACS (RAS-ACS) and collaborative efforts with the College’s leadership and its state chapters, Resident Members and Associate Fellows maintain the tradition of physician advocacy.15,16 This article describes recent regulatory and legislative efforts championed by surgeon advocates and their continued impact on current and future generations of surgeons, including the following: physician payment reform; current efforts to protect and preserve the workforce through Graduate Medical Education (GME); and the future of surgeon-led advocacy, particularly the work of the RAS-ACS Issues and Advocacy Committee.
The College’s state advocacy efforts enable swift and nimble responses to changes at the regional level. The ACS maintains a well-organized state-level surveillance mechanism. One Councilor from each ACS chapter functions as the advocacy expert and is responsible for its grassroots advocacy efforts. Surgeons also can participate in the District Office Contacts by Surgeons Program, which fosters close relationships between state policy leaders and individual surgeons, who then serve as resources to their elected officials on changes and challenges in health care policy. College members who would like to have their finger on the pulse of statewide legislative agendas also may participate in the ACS Councilor program and act as the “eyes and ears” of the State Affairs team in the ACS Division of Advocacy and Health Policy, Washington, DC.
Surgeons also are encouraged to take action at the local level by participating in the Advocacy Lobby Day Grant Program. The ACS supports chapter lobby days by offering the State Lobby Day Toolkit and matching grants of up to $5,000.17
SurgeonsVoice is another way the College provides members with support at the local level by offering an online resource for engaging in state advocacy initiatives, including Surgeons as Advocates: A Guide to Successful State Advocacy, a comprehensive handbook on effective, sustainable campaigns for local and regional leaders.18 All of these resources foster lasting relationships between surgeons and their elected state officials. By becoming knowledgeable and respected champions for surgical patients and practice, state-level advocates serve as an invaluable point of contact for their elected officials as well as a link between legislators and the ACS.
The ACS has concentrated state-level efforts in several issue areas. One example is quality and patient safety, which includes injury prevention efforts and scope-of-practice regulations.19 Surgeons have been especially effective in various states in lending their voice in support of injury prevention legislation, including seatbelt regulation, helmet laws, youth athlete concussion education and prevention, prevention of falls in elderly patients, child safety restraints, and regulation of all-terrain vehicles.19 Scope-of-practice efforts have recently focused on developing guidelines for complex surgical procedures by nonphysician providers.19
Another area of state-level focus is the implementation of the Uniform Emergency Volunteer Health Practitioners Act (UEVHPA), model legislation that allows state governments to give licensing reciprocity to emergency and disaster personnel from other states. Local surgeon advocates, with the support of the ACS and their state chapters, have called for passage of the bill in multiple states, and successful versions of the bill have passed in Arkansas, Colorado, Illinois, Indiana, Kentucky, Louisiana, Nevada, New Mexico, North Dakota, Oklahoma, Oregon, Tennessee, Texas, Utah, and the District of Columbia. Implementation of this act is an ongoing process, with recent focus on passing versions of the UEVHPA in Georgia and Pennsylvania.
The ACS also supports state-level policies related to physician payment, including Medicaid reimbursement; classification of certain surgical procedures, such as bariatric surgery, as essential insurance benefits; and opposition of restricted networks for insurance sold on state exchanges.19
At the federal level, recent legislative priorities have included Medicare physician payment, maintenance of the fee-for-service payment model, support for a merit-based approach to achieving benchmarks for incentive programs such as the meaningful use program for electronic health records, the Value-Based Payment Modifier Program, and the Physician Quality Reporting System, as well as reduction of administrative burden of these programs.20 Medical liability reform is a perennial topic of concern, and most recently, the ACS supported the Saving Lives, Saving Costs Act (H.R. 4106), which proposes the establishment of independent medical review panels to evaluate liability lawsuits, provide liability protections, and discourage frivolous litigation while promoting patient safety.21 Similarly, the College’s efforts have spotlighted liability protection for trauma providers, such as the Health Care Safety Net Enhancement Act (H.R. 836/S. 884) and the Good Samaritan Health Professionals Act (H.R. 865).22
Repeal of the SGR
A notable and successful recent effort by the ACS, in collaboration with dozens of specialty societies and physician groups, was the repeal of the SGR. A product of the 1997 federal budget negotiations, the SGR tied Medicare payment rates to growth in U.S. gross domestic product (GDP) to rein in health care spending; when physician spending grew less than GDP, reimbursement would increase, and vice versa.
Each year since 2002, the SGR would trigger cuts in Medicare reimbursement as a result of high health care spending relative to the concomitant change in the GDP, bringing with it the threat of decreased patient access to physicians. In response, Congress passed 17 retroactive, increasingly expensive stop-gap funding bills to cover the budgeting shortfall, a practice nicknamed the annual “doc fix.”
The ACS played a leading role in a multispecialty coalition to repeal the SGR. Year after year, Medicare physician reimbursement remained a top legislative priority, but despite general agreement among members of Congress that the SGR was a failed experiment, attempts to replace the flawed formula repeatedly stalled due to disagreements about the potential alternative and how to fund it.23 Persistent efforts by ACS Fellows and staff eventually came to fruition. The multi-year initiative ultimately succeeded with the passage of MACRA, which set automatic increases for Medicare reimbursement rates until 2019 and outlined a Merit-based Incentive Payment System (MIPS) program to launch thereafter.24
The ACS was in the vanguard of SGR repeal efforts for more than a decade, supporting ACS Fellows in advocacy efforts in their cities and states, carrying out sustained federal lobbying on the issue, and strategizing with other medical groups.23 The success of the campaign was a testament to the importance and potential of surgical advocacy at the federal level and meaningfully demonstrated why surgeons need to stay abreast of health policy changes that will affect their practices, their patients, and their collective effort to improve the delivery of surgical care.
Preserving the surgical workforce
As Resident Members of the ACS look to the future of surgical advocacy, several issues present both challenges and opportunities for the health care profession. Graduate medical education reform efforts to train and maintain the health care workforce is a priority across every specialty of medicine because the consequences of a physician shortage will be felt for years to come. During the past decade, the number of seats in U.S. medical schools has come under scrutiny as estimates suggested that schools were graduating too few physicians to replace those retiring.25 Through diverse federal and state funding programs and public–private partnerships, more than a dozen new medical schools have matriculated their first classes in the last five years, boosting the physician supply by several hundred graduates each year.26
However, GME has become a new bottleneck as the number of federally funded residency positions remains capped and insufficient, not only to meet projected demand for medical care two decades from now, but also to satisfy the immediate demand for postgraduate training by growing numbers of U.S. medical school graduates. The Association of American Medical Colleges has estimated that within 10 years, demand for physicians will outstrip supply by up to 90,000.27,28
Whereas early projections pointed to primary care as the area of greatest need, newer models now underscore an urgent need for both generalists and specialists, who may account for half or more of the shortfall.29 So, to meet the health care needs of the nation’s aging population, an increase in the number of physicians of every kind, including general and subspecialty surgeons, will be required. Because postgraduate surgical training takes five to 10 years, the time for GME reform to alleviate demand a decade from now has already arrived.
The ACS has articulated principles to guide responses to proposals to renew, replace, or reorganize the GME system.30 First, the ACS supports the recommendation from the Institute of Medicine (now the National Academy of Medicine) to establish a GME transformation fund, which would aid in the development and assessment of new GME programs, performance measures, and payment models. Second, the ACS is interested in proposals for a regionalized GME governance system—akin to existing systems used in organ procurement or trauma care—that could respond more flexibly to the changing demographics and health care needs of a specific population. Third, underscoring an ongoing need for comprehensive, reliable evidence on the workforce, the ACS supports the systematic collection and reporting of national workforce data so that the projections on which policies are crafted remain evidence-based.
Companion bills have been introduced in Congress to address workforce deficiencies. The Resident Physician Shortage Reduction Act (H.R. 2124/S. 1148) increases the number of residency positions by 15,000 over five years and, notably, recognizes the need for both primary care and specialist physicians by directing that half of the new positions be in critical need fields, such as the surgical specialties. The legislation also outlines criteria for distributing the new positions, such as by giving priority to states with new medical schools. As of June 2016, the House bill had more than 100 bipartisan cosponsors; the Senate version had 14 Democrat cosponsors.
Other bills have addressed GME issues through various funding mechanisms, regulatory reforms, and programs to study geographic variation in the projected shortage. Continued review of legislation by surgeons and surgical advocates will be critical to ensure that proposed reforms are consistent with anticipated changes in the surgical workforce and in patient needs.
The road ahead: Inspiring future surgeon advocates
GME reform is not the only active issue that should be on surgeons’ minds. A dozen other priorities, ranging from cancer research appropriations to quality metrics being incorporated into Medicare payment models, offer diverse points of entry into advocacy for surgeons in every practice setting and specialty, with all levels of experience and interest. Examples are as follows:
- The metrics for MIPS payment, which will be adjusted based on physician performance in defined categories (quality, resource use, clinical practice improvement activities, and meaningful use), still need to be articulated and to accurately reflect how surgical care is delivered.31
- President Obama’s National Cancer Moonshot Initiative to accelerate cancer research and discovery has underscored the work of a coalition of cancer-advocacy organizations, including the ACS. This coalition has lobbied Congress for increased federal funding for cancer research and prevention programs through the National Institutes of Health and Centers for Disease Control and Prevention.32
- Challenges related to the widespread adoption of health information technology remain a concern, including electronic health record security and interoperability; and the rollout of the International Classification of Diseases, 10th revision, for coding, billing, and disease data collection.33
- Bills reauthorizing regional trauma systems and grants for emergency care pilot projects, as well as providing federal assistance to critical-access trauma centers for uncompensated costs, passed the House (H.R. 648) in 2015 but stalled in the Senate and have yet to be addressed.22
The RAS-ACS Issues and Advocacy Committee has been an active partner with the ACS Division of Advocacy and Health Policy to inspire and train the next generation of leaders in surgical advocacy. The committee sponsors resident-led initiatives to engender discussion related to surgical training, provides forums for conflicting viewpoints, and helps outline guidance in areas of controversy. Most recently, the RAS-ACS Symposium at Clinical Congress 2015 addressed surgeon engagement with social media in their professional lives.34 The robust discussions during the symposium prompted the RAS-ACS Issues and Advocacy Committee to appoint a workgroup of trainees and ACS members to develop guidelines on social media use, a timely adjunct to the ACS Statements on Principles for surgeon professionalism.
Like previous generations of surgeons whose advocacy efforts addressed new challenges to patient safety and surgical care, contemporary surgeons and trainees face issues that will evolve with the shifting political landscape and practice patterns. Dedicated surgeon engagement in local, state, and federal advocacy will be imperative to combat regulatory and legislative threats to quality, access, payment, and the surgical workforce. The past successes of the ACS reflect the commitment of surgeon leaders across the nation whose boots on the ground approach paved the way forward. Together, surgeons of today and tomorrow have an unprecedented opportunity to shape the direction and potential of surgical advocacy, ensuring the protection of our patients and the future of our profession.
The authors would like to thank Sara Morse, Manager, Legislative and Political Affairs, ACS Division of Advocacy and Health Policy, Washington, DC, for her assistance with this article.
- Prabhakaran S, Economopoulos KP, Grabo DJ, Sakran JV. Surgical leadership across generations. Bull Am Coll Surg. 2012;97(8):30-35.
- Liepert AE. Applying advocacy skills: Gaining influence from the statehouse to Capitol Hill. Bull Am Coll Surg. 2016;101(3):25-29.
- Steinberg SM, Zinner MJ, Ellison EC. Health policy program produces surgeon advocates and leaders. Bull Am Coll Surg. 2014;99(3):22-27.
- Ackerman TL, Rosen J. Surgeons as state advocates. Bull Am Coll Surg. 2014;99(9):33-37.
- Ogunleye AA, Bliss LA, Kuy S, Leichtle SW. Political advocacy in surgery: The case for individual engagement. Bull Am Coll Surg. 2015;100(8):40-44.
- Maa J, Sutton JH. The defeat of Proposition 46 in California: A case study of successful surgeon advocacy. Bull Am Coll Surg. 2016;101(1):61-63.
- Mabry CD, Harris C. ACS Health Policy Advisory Council aims to empower fellows as advocates. Bull Am Coll Surg. 2012;97(2):48-49.
- Carmody M, Oehmen K. Advocacy and grassroots: Leveraging local issues at the national level. Bull Am Coll Surg. 2015;100(10):23-27.
- Morse S. SurgeonsVoice: Your patients, your profession, your voice. Bull Am Coll Surg. 2014;99(7):28-30.
- Walter KR. 2015 Advocacy program: Attendees learn the power of a unified voice. Bull Am Coll Surg. 2015;100(7):83-86.
- Hughes KA. Why are you here? To lead, to advocate, and to connect. Bull Am Coll Surg. 2015;100(7):80-82.
- American College of Surgeons. ACS declares victory with passage of law repealing the SGR. Bull Am Coll Surg. 2015;100(6):51.
- Steinbrook R. The repeal of Medicare’s sustainable growth rate for physician payment. JAMA. 2015;313(20):2025-2026.
- American College of Surgeons. Advocacy Committees. Available at: facs.org/advocacy/committees. Accessed April 2, 2016.
- Grant SB, Hon H, Iver P, Smith C, Sun S. The RAS-ACS: Recruiting medical students and training future leaders. Bull Am Coll Surg. 2015;100(8):23-28.
- Babu M. The view from the Chair of the RAS-ACS. Bull Am Coll Surg. 2016;101(2):27-29.
- American College of Surgeons. Chapter Advocacy Lobby Day Grant Program. Available at: facs.org/advocacy/state/chapter-grant. Accessed April 23, 2016.
- American College of Surgeons. Surgeons as Advocates: A Guide to Successful State Advocacy. Available at: facs.org/~/media/files/advocacy/state/surgeons%20as%20advocates%20handbook.ashx. Accessed April 23, 2016.
- American College of Surgeons. Legislative priorities: quality/patient safety. Available at: facs.org/advocacy/state/trends. Accessed April 23, 2016.
- American College of Surgeons. Medicare physician payment. Available at: facs.org/advocacy/federal/medicare. Accessed April 23, 2016.
- American College of Surgeons. Surgeons and Medical Liability: A Guide to Understanding Medical Liability Reform. Available at: facs.org/~/media/files/advocacy/liability/2014%20surgeons%20and%20medical%20liability%20primer.ashx. Accessed April 23, 2016.
- American College of Surgeons. Trauma and EMS. Available at: facs.org/advocacy/federal/trauma-and-ems. Accessed April 23, 2016.
- Hedstrom J. The SGR repeal: How bad politics ruined sound policy. Bull Am Coll Surg. 2014;99(6):9-12.
- Clemens J, Veuger S. Repeal of the Medicare sustainable growth rate: Direct and indirect consequences. AMA J Ethics. 2015;17(11):1053-1058.
- Association of American Medical Colleges. The impact of health care reform on the future supply and demand for physicians updated projections through 2025. Available at: www.aamc.org/download/158076/data/updated_projections_through_2025.pdf. Accessed April 23, 2016.
- Association of American Medical Colleges. A snapshot of the new and developing medical schools in the U.S. and Canada. Washington, DC: 2012. Available at: members.aamc.org/eweb/upload/A%20Snapshot%20of%20the%20New%20and%20Developing%20Medical%20Schools%20in%20the%20US%20and%20Canada.pdf. Accessed June 17, 2016.
- Association of American Medical Colleges. The Complexities of Physician Supply and Demand: Projections from 2013 to 2025. March 2015. Available at: www.aamc.org/download/426248/data/thecomplexitiesofphysiciansupplyanddemandprojectionsfrom2013to2.pdf. Accessed April 23, 2016.
- Association of American Medical Colleges. April 2016. 2016 Update: The Complexities of Physician Supply and Demand: Projections from 2014 to 2025. Available at: www.aamc.org/download/458082/data/2016_complexities_of_supply_and_demand_projections.pdf. Accessed April 23, 2016.
- Association of American Medical Colleges. 2014 Physician Specialty Data Book. Washington, DC: 2014. Available at: members.aamc.org/eweb/upload/Physician%20Specialty%20Databook%202014.pdf. Accessed June 17, 2016.
- American College of Surgeons. American College of Surgeons Graduate Medical Education Principles & Priorities. Available at: facs.org/~/media/files/advocacy/gme/acs%20gme%20principles%20and%20priorities%201_15.ashx. Accessed April 23, 2016.
- Coffron M, Ollapally V. Preparing for MACRA implementation. Bull Am Coll Surg. 2016;101(2):30-32.
- American College of Surgeons. Cancer and Research. Available at: facs.org/advocacy/federal/cancer. Accessed April 25, 2016.
- Resnick CM, Meara JG, Peltzman M, Gilley M. Meaningful use: A program in transition. Bull Am Coll Surg. 2016;101(3):10-16.
- Azoury SC, Bliss LA, Ward WH, Liepert AE, Leichtle SW. Surgeons and social media: Threat to professionalism or an essential part of contemporary surgical practice? Bull Am Coll Surg. 2015;100(8):45-51.