Editor’s note: The American College of Surgeons (ACS) Board of Governors (B/G) conducts an annual survey of its domestic and international members. The purpose of the survey is to provide a means of communicating the concerns of the Governors to the College leadership. The 2019 ACS Governors Survey, conducted in July 2019 by the B/G Survey Workgroup, had a 95 percent (276/289) response rate.
One of the survey’s topics was regulatory burden. This article outlines the Governors’ feedback on this issue.
Regulatory requirements and associated administrative burden mandated by Congress, other federal agencies, and state health care administrations have a profound effect on surgeons and surgical practices. The Medscape Physician Compensation Report 2019 showed a startling increase in paperwork, even beyond previous years. In the 2018 Medscape report, nearly one-third of physicians indicated they spend 20 hours or more a week on paperwork and administrative tasks. (In 2020, an average of 15.6 hours per week was spent on administrative tasks so there is a slight decrease this year.)
This administrative burden takes physician and staff time away from the clinic and the operating room, diminishing access to high-quality services and patient care. This regulatory burden also is a principle driver of physician burnout and medical errors.
Increased prior authorization activities also have taken more time away from patient care. A study by George Mason University, Fairfax, VA, shows a relationship between increasing regulatory burdens and declining patient safety. At an American Medical Association (AMA) conference in February 2020, the Centers for Medicare & Medicaid Services (CMS) Administrator, Seema Verma, MPH, acknowledged the negative effects of these administrative tasks on practices and patient care and called for a reduction in regulations.
Patient safety and practice efficiency
Because of patient safety concerns and the technical complexity of patient care, health care will continue to be a highly regulated industry. However, there is a sweet spot of appropriate professional regulation before additional rules and limitations detract from an efficient and safe practice environment. Although most ACS Governors (68 percent) agreed/strongly agreed regulations are necessary to improve the quality of care, this sentiment varied based on geographic distribution. For example, more international Governors (93 percent) and Canadian Governors (83 percent) believed regulation contributed to a higher quality practice than U.S. Governors (63 percent). Despite a beneficial effect on quality, most Governors (81 percent) said they believe increased regulations make their practice less efficient (see Figure 1) with more U.S. Governors (87 percent) expressing this opinion than international Governors (59 percent) and Canadian Governors (58 percent). It appears from our high-level survey data that a more balanced approach to the type and quantity of required regulations would support better care and practice in surgery.
Figure 1. Effects of regulation on surgical practice
Figure 2. Increased regulatory burdens affect my decision to retire
Impact on practice
Various professional medical organizations and the American Hospital Association have studied and documented the effect of overregulation on practices; physician burnout and early retirement often are cited as consequences. Increasing regulation was noted by 33 percent of Governors as a strong contributing factor to early retirement (see Figure 2). Consideration of early retirement was more common among U.S. Governors (37 percent) than Canadian Governors (25 percent) or international Governors (13 percent). Interestingly, 13 percent more women than men plan to retire early. In an era of surgical workforce shortages, the fact that so many surgeons are considering early retirement and citing regulatory burden as a major factor in their decision is a cause for concern.
Billing and reimbursement are driven by clinical activity, as captured in clinical documentation. At present, the effects are reflected in the electronic health record. The dual roles of documentation to support compliant billing and clinical care has created an increasing documentation burden and has taken time away from clinical care. Many Governors indicated that decreasing the volume and types of documentation that detract from patient care is essential. Governors said they would reconsider early retirement if they had more autonomy to collaborate with patients and families on decision making and if arcane insurance regulation were minimized.
For many international Governors, the threat of bureaucracy in which they have no say or control was the primary reason for choosing early retirement. Reduced paperwork and better professional and economic security would help them reconsider their early retirement plans.
Governors said they believe insurance company regulations were the most onerous (37 percent), followed by hospital regulations (30 percent), then national regulations (23 percent). State/province regulations were considered the least burdensome (7 percent).
Clearly, all types of regulations have considerable impact on surgeons (see Table 1). Most international Governors (37 percent) reported that national regulations had the greatest effect on their practices.
Table 1. How regulations affect surgical practice, ranked (4 = least burdensome)
The survey explored awareness of ACS advocacy efforts in two areas, the College’s Stop Overregulating My OR (SOMO) initiative and implementation of the Medicare Access and Children’s Health Insurance Program Reauthorization Act (MACRA), which introduced the Merit-based Incentive Payment System (MIPS).
To combat policies that could further weigh down surgeons and their practices, the College launched the SOMO initiative in 2017. Through this campaign, the ACS Division of Advocacy and Health Policy (DAHP), Washington, DC, has highlighted regulatory and legislative actions that should be taken to streamline surgical administrative activities and enable surgeons to reinvest their time in high-quality patient care.
Despite reports to the B/G about this work from ACS Executive Director David B. Hoyt, MD, FACS, and ACS leaders, only 11 percent of Governors said they were extremely familiar with SOMO, 21 percent were moderately familiar, and 36 percent were not familiar at all (see Figure 3). The survey indicates an opportunity for improved awareness and Governor participation in SOMO.
Although most Governors (55 percent) were extremely or moderately satisfied with how the College addresses MACRA, MIPS, and other reimbursement issues, many Governors were slightly satisfied or not at all satisfied with how the ACS addresses clinical documentation requirements (56 percent), interoperability and the EHR (64 percent), prior authorization (60 percent), and private payor issues (61 percent) (see Table 2). Governors suggested that the College should advocate for surgical specialty-specific regulations. Additional awareness and communication of current advocacy efforts and goals are warranted.
Figure 3. Familiarity with SOMO
Table 2. Level of satisfaction with ACS efforts to address regulatory burdens
Many Governors provided recommendations to reduce overregulation. Examples included standardized coding and billing requirements from insurers and government agencies. They also suggested more collaboration with CMS and insurers to reduce other aspects of administrative workload, such as prior authorization. Strategies to increase workplace efficiencies, building on prior ACS efforts that have reaped positive responses, also were recommended. Because of their variable geographic locations and different regulatory laws, international Governors were unable to provide feedback on how the ACS could lessen regulatory burdens, though they acknowledged this is a significant problem for their practices around the world.
Most Governors (70 percent) said they believe the College should address regulatory burdens and raise visibility and attention, whereas only 21 percent believed it was moderately important (see Figure 4). Notably, 93 percent of international Governors indicated they found the regulatory environment to be an extremely or moderately important issue for the College to continue to address.
Figure 4. Importance of the College continuing to address regulatory burdens
The survey demonstrates that burdensome overregulation continues to adversely affect surgeons, but there are several opportunities for improvement and ACS action. Encouraging Fellows to share their regulatory burden experiences and continuing to aggressively work the issue at the health care insurer, federal, and state levels seems important to most Governors. The ACS also could better promote and expand the SOMO program. Hospital regulations should be adjusted through surgeon-led, medical staff initiatives. Rules promulgated by state, federal, and other agencies must be addressed at the source aggressively through advocacy efforts that make legislators and regulators aware of unintended but real adverse clinical consequences when new policies are proposed.
The ACS and other professional organizations have an opportunity to act, advocate, and collaborate on the national level. This opportunity is a unique strength, role, and privilege. Surgical and medical associations should collectively advocate for a proper balance of safety with regulations that support integrated, quality care and the patient-surgeon relationship. Reducing unnecessary and burdensome regulations will preserve our workforce, reduce burnout, increase access for patients, and promote better, higher-quality patient care through better communication and a reduction in errors.
Advocacy is a collaborative effort and to be successful the College must engage and educate Fellows about health policy priorities. In turn, Governors and, indeed, all Fellows must participate by taking action on legislative issues of importance to them and their patients, as well as providing feedback when requested. Together, we can strive to reduce unnecessary regulatory burdens and ensure that patients continue to receive care that meets the College’s quality and safety standards.
American Academy of Family Physicians sustains fight to reduce administrative complexity for family medicine. Available at: www.aafp.org/media-center/kits/aafp-sustains-fight-to-reduce-administrative-burden-for-family-medicine.html. Accessed March 18, 2020.
American College of Physicians. Reducing administrative burdens. State health policy. Available at: www.acponline.org/advocacy/state-health-policy/reducing-administrative-burdens. Accessed March 18, 2020.
American College of Surgeons: Advocacy. Available at: www.facs.org/advocacy/regulatory/somo. Accessed March 20, 2020.
American Hospital Association. Regulatory Overload Report. November 3, 2017. Available at: www.aha.org/guidesreports/2017-11-03-regulatory-overload-report. Accessed March 19, 2020.
Boden AP, Boucek B, Larkin PL Jr., et al. Managing the regulatory thicket: Cumulative burdens of state and local regulation. Regulatory Transparency Project. Available at: https://regproject.org/paper/managing-the-regulatory-thicket/3. Accessed March 19, 2020.
Bowen R. Do more regulations equal less safety? Mercatus Center, George Mason University. Available at: www.mercatus.org/system/files/More-Regulations-Less-Safety.pdf. Accessed March 19, 2020.
Centers for Medicare & Medicaid Services. CMS seeks public input on patients over paperwork initiative to further reduce administrative, regulatory burden to lower healthcare costs. Available at: www.cms.gov/newsroom/press-releases/cms-seeks-public-input-patients-over-paperwork-initiative-further-reduce-administrative-regulatory. Accessed March 23, 2020.
Dickson V. Physicians’ regulatory burden worse than ever despite federal efforts. Modern Healthcare. October 4, 2018. Available at: www.modernhealthcare.com/article/20181004/NEWS/181009951/physicians-regulatory-burden-worse-than-ever-despite-federal-efforts. Accessed August 5, 2020.
Murphy K. Administrative burden remains top challenge for physicians. EHR Intelligence. Available at: https://ehrintelligence.com/news/administrative-burden-remains-top-challenge-for-physicians. Accessed March 18, 2020.
The Office of the National Coordinator for Health Information Technology: Strategy on reducing regulatory and administrative burden relating to the use of health IT and EHRs. Available at: https://www.healthit.gov/topic/usability-and-provider-burden/strategy-reducing-burden-relating-use-health-it-and-ehrs. Accessed March 18, 2020.
Schulte F, Fry E. Death by 1000 clicks: Where electronic health records went wrong. Kaiser Health News. March 2019. Available at: https://khn.org/news/death-by-a-thousand-clicks/. Accessed March 19, 2020.