2016 ACS Governors Survey: Issues affecting surgical practice

Editor’s note: The American College of Surgeons (ACS) Board of Governors (B/G) has conducted an annual survey of its members for more than 20 years. The purpose of the survey is to provide a means of communicating the Governors’ concerns to the College leadership. The 2016 ACS Governors Survey, conducted in August 2016, had an 84 percent (230/274) response rate.

The following article focuses on Governors’ responses to questions about the effects of advocacy and health policy on a surgical practice. This article is the last in a series of four articles that highlight key issues addressed in the 2016 ACS Governors Survey.

Many advocacy and health policy issues affect surgical practice today. In the 2016 Governors Survey, respondents were asked to rank the various issues that could have an effect on their practice.

ACS Governors are members of many different types of surgical practices. A specific issue or advocacy issue may be important to surgeons in one type of practice, but not a priority for surgeons in another type of surgical practice. And certainly, some health policy and advocacy-related matters are important to surgeons in all types of surgical practice. In this study, we seek to determine if ACS Governors in different types of surgical practice have different levels of concern regarding health policy or advocacy issues that could affect their surgical practice.

Issues affecting surgical practice

In the 2016 ACS Governors Survey, respondents were asked to select their top 10 areas of concern from a list of 25 issues. (Table 1 ranks the Governors’ issues of concern.)

Table 1. Issues of concern

Issues of concern in order of importance	Number of Governors
Continuing medical education (CME)/Maintenance of Certification (MOC)	128
Funding for graduate medical education (GME)	119
Physician reimbursement/Medicare/Medicaid	116
Competency measurement for the practicing surgeon	113
Public reporting of performance measures	113
Pay for performance	107
Electronic health records	107
Readiness of a newly graduated surgical resident to assume independent practice	105
Professional liability/malpractice/tort reform	102
Long-term workforce issues for general surgery/surgical specialties	99
Maintaining an adequate work/lifestyle balance	96
Health care reform through the Affordable Care Act and its impact on your practice	91
Having enough surgeons available to take call for general surgery and the surgical specialties	84
Overspecialization of the field of surgery	76
Trauma care	71
Regionalization of surgical services	70
Advocacy efforts at the state and national level	70
Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act (MACRA) concerns	67
Preserving the option of private practice for surgeons	65
Relationships and contracting with hospitals/managed care organizations/accountable care organizations	58
Peer review issues	56
Credentialing for new technology/hospital privileges issues	54
Merit-based Incentive Payment System concerns	31
Physician Quality Reporting System concerns	27
Availability of surgical supplies in the hospital (staplers, mesh, suture, and so on)	21

ACS Governors work in different types of surgical practice settings, and with this in mind, they were asked to specify their type of surgical practice (see Table 2). The three most common types of surgical practice for survey respondents were full-time academic practice (49 percent), private practice (23 percent), and full-time hospital-employed physician (15 percent).

Table 2. ACS Governors and surgical practice settings

Type of surgical practice setting	Percent of responses
Full-time academic practice	49%
Private practice	23
Full-time hospital-employed physician	15
Other	11
Governmental agency	2

The data regarding responses to issues of importance to ACS Governors was further analyzed to determine if the responses varied for participants working in full-time academic practice, full-time hospital-employed practice, or private practice. We were curious to see whether each setting had its own issues of concern and whether some of the issues were important to surgeons in all three group settings. Responses based on the type of practice are outlined in Table 3.

Table 3. Top 10 issues based on practice type*

Order of importance (1 highest– 10 lowest)	Full-time academic practice	Full-time hospital-employed physician	Private practice
1	Funding for GME	Long-term workforce issues for general surgery/surgical specialties	Preserving the option of private practice for surgeons
2	CME/MOC	CME/MOC	Physician reimbursement/ Medicare/Medicaid
3	Public reporting of performance measures	Having enough surgeons available to take call for general surgery and the surgical specialties	Electronic health records
4	Physician reimbursement/ Medicare/Medicaid	Public reporting of performance measures	Pay for performance
5	Competency measurement for the practicing surgeon	Electronic health records	Professional liability/malpractice/tort reform
6	Readiness of a newly graduated surgical resident to assume independent practice	Physician reimbursement/ Medicare/Medicaid	Competency measurement for the practicing surgeon
7	Maintaining an adequate work/lifestyle balance	Pay for performance	Health care reform through the Affordable Care Act, and its impact on your practice
8	Pay for performance	Funding for GME	CME/MOC
9	Long-term workforce issues for general surgery/surgical specialties	Readiness of a newly graduated surgical resident to assume independent practice	Public reporting of performance measures
10	Professional liability/ malpractice/tort reform	Health care reform through the Affordable Care Act, and its impact on your practice	Funding for GME

*Each issue is color-coded to indicate where the same issue is ranked by the different practice types.

Clearly, issues of concern are tied to practice setting. Surgeons in each practice environment have a different set of concerns than those in another setting, and notably, the top issue of concern for each practice setting group doesn’t come near the top issue of concern for the other two groups. Funding for graduate medical education (GME), the top issue of concern for surgeons in full-time academic practice, is ranked eighth by respondents in a full-time hospital-employed position, and number 10 for those in private practice. The number one issue of concern for those in a full-time hospital-employed position—long-term workforce issues for general surgery/surgical specialties—is ranked ninth by respondents working in a full-time academic practice, while that issue of concern isn’t even ranked in the top 10 by those in private practice. The top issue of concern for those in private practice—preserving the option of private practice for surgeons—isn’t ranked in the top 10 in either of the other practice setting groups.

Nonetheless, five issues ranked in the top 10 for ACS Governors in all three practice setting groups:

• Continuing medical education (CME)/Maintenance of Certification (MOC)
• Funding for GME
• Physician reimbursement/Medicare/Medicaid
• Public reporting of performance measures
• Pay for performance

It is clear that the ACS Governors’ level of concern for issues that affect a surgical practice vary by type of surgical practice. For Governors in a specific type of surgical practice, some of the issues could be very important (top), moderately important (mid-level), or not very important (low-priority).

To categorize the issues outlined in Table 3 into top, mid-level, and low-priority issues, the following system was used: 14 different issues are listed in Table 3. For any specific surgical practice type, if an issue was ranked 1–3, it was assigned to the top category. Any issue ranked 4–8 was labeled mid-level, and any issue ranked 9, 10, or unranked was categorized as low-priority. Table 4 shows which issues are top, mid-level, or low-priority for each of the three types of surgical practice settings.

Table 4. Top, mid-level, and low-priority issues for each surgical practice type

Issue	Full-time academic practice	Full-time hospital- employed physician	Private practice
CME/MOC	Top	Top	Mid-level
Physician reimbursement/Medicare/Medicaid	Mid-level	Mid-level	Top
Funding GME	Top	Mid-level	Low-priority
Public reporting of performance measures	Top	Mid-level	Low-priority
Electronic health record	Low-priority	Mid-level	Top
Pay for performance	Mid-level	Mid-level	Mid-level
Competency measurement for the practicing surgeon	Mid-level	Low-priority	Mid-level
Long-term workforce issues for general surgery/surgical specialties	Low-priority	Top	Low-priority
Preserving the option of private practice for surgeons	Low-priority	Low-priority	Top
Having enough surgeons available to take call for general surgery and the surgical specialties	Low-priority	Top	Low-priority
Readiness of a newly graduated surgical resident to assume independent practice	Mid-level	Low-priority	Low-priority
Maintaining an adequate work/lifestyle balance	Mid-level	Low-priority	Low-priority
Professional liability/malpractice/tort reform	Low-priority	Low-priority	Mid-level
Health care reform through the Affordable Care Act, and its impact on your practice	Low-priority	Low-priority	Mid-level

Advocacy issues

The ACS Division of Advocacy and Health Policy, Washington, DC, is actively advocating on behalf of surgeons in many areas that affect the surgical care of patients. To determine which specific advocacy issues Governors felt were most important, survey respondents were asked to rank a list of 12 issues by order of importance. Table 5 outlines the top advocacy issues based on the overall response from survey participants.

Table 5. Ranking of advocacy issues by ACS Governors

Advocacy issue (in order of importance)

Establishment of quality metrics

Physician payment under fee for service with quality metrics

GME reform

Physician payment under APMs

Surgical workforce, general surgery

Liability/tort reform

Trauma care

Public reporting of performance measures

Cancer care

Research funding

Electronic health record (meaningful use)

Surgical workforce, surgical specialties

Responses regarding importance of advocacy issues also were analyzed based on the type of practice of the respondent, and these data are shown in Table 6. All three groups ranked three advocacy-related issues in the top five:

• Establishment of quality metrics
• Physician payment under fee for service with quality metrics
• Physician payment under Alternate Payment Models (APMs)

Table 6. Analysis of top five advocacy issues based on practice type

Order of importance (1 highest– 5 lowest)	Full-time academic practice	Full-time hospital- employed physician	Private practice
1	GME reform	Establishment of quality metrics	Physician payment under fee for service with quality metrics
2	Establishment of quality metrics	Physician payment under fee for service with quality metrics	Physician payment under APMs
3	Research funding	Surgical workforce—general surgery	Liability/tort reform
4	Physician payment under APMs	Physician payment under APMs	Surgical workforce—general surgery
5	Physician payment under fee for service with quality metrics	GME reform	Establishment of quality metrics

It’s clear that the use of quality metrics in determining physician payment is an important advocacy-related topic for all three groups of survey respondents.

The three groups of surgeons have apparent differences of opinion on other advocacy issues. Each group of surgeons had a different top-ranked advocacy issue. GME reform was the number one advocacy issue for those in full-time academic practice, while it was ranked fifth by full-time hospital-employed physicians and was not ranked in the top five by those in private practice. The issue of establishment of quality metrics was ranked first by full-time hospital-employed physicians. For those in private practice, the issue of physician payment under fee-for-service with quality metrics was ranked number one.

Other advocacy-related issues were supported by some of the groups, but not all of them. In order to categorize the issues from Table 6 into top, mid-level, and low-priority advocacy issues for ACS Governors in the three surgical practice types evaluated in this survey, the following system was used: Seven different advocacy issues are listed in Table 6. For any specific surgical practice type, if an advocacy issue was ranked 1–2, it was labeled top. Any issue ranked 3–4 was called mid-level. Any issue ranked 5 or unranked was categorized as low-priority. Table 7 shows which issues were top, mid-level, or low-priority for each of the three types of surgical practice.

Table 7. Top, mid-level, and low-priority advocacy issues for each surgical practice type

Advocacy issue	Full-time academic practice	Full-time hospital-employed physician	Private practice
Establishment of quality metrics	Top	Top	Low-priority
Physician payment under fee for service with quality metrics	Low-priority	Top	Top
Physician payment under APMs	Mid-level	Mid-level	Top
Surgical workforce—general surgery	Low-priority	Mid-level	Mid-level
GME reform	Top	Low-priority	Low-priority
Research funding	Mid-level	Low-priority	Low-priority
Liability/tort reform	Low-priority	Low-priority	Mid-level

Conclusions

In this study of the 2016 ACS Governors’ Survey data, we attempted to determine whether Governors in a full-time academic practice, a full-time hospital-employed physician practice, and a private practice had different levels of concern for health policy and advocacy-related issues that could affect their surgical practice.

Based on the data presented in this article, it is evident that some of these issues are important enough that surgeons in all three types of practice ranked them as top issues. Other topic areas were found to be very important to Governors in one type of practice, but not necessarily important to Governors in the other types of surgical practice. Governors in each type of surgical practice have their own unique areas of concern.

These findings have implications for the ACS leadership and the ACS Division of Advocacy and Health Policy, who work to help and support all ACS Fellows regardless of surgical practice and will assist College leaders with prioritizing their efforts in the future.