Health policy advocacy has become a much more accepted and necessary mark of professionalism in surgery. With the ever-advancing systems of surgical care delivery, payment reforms, regulations, and the consolidation of practices to hospital systems, the need for surgeon involvement and participation in advocacy is imperative.
Surgical health policy advocacy has been an important component of the coronavirus 2019 (COVID-19) pandemic response. The nation’s health care systems at all levels were required to quickly pivot to respond to canceled elective and nonurgent operations, decimated budgets, and a ramp-up of emergency responses to a potentially high influx of patients with a new disease with a seemingly ever-evolving complexity of constellation of symptoms. Surgeons emerged as leaders in their hospitals, communities, states, and nationally. Whether it is that natural leadership skill set that surgeons have or learned traits of control of complexity in the operating room or trauma bay—triage, direction, leadership, and reflection are invaluable attributes throughout this crisis.
Despite the increased focus on public health, as well as massive shifts in care delivery and preexisting local, state, and surgical policy issues, the politics did not completely dissolve even as they appeared tempered in the midst. Because COVID-19 remains a priority health policy for state and local governments, health care issues important to the profession of surgery and delivery of quality patient care remain at all levels of government.
Challenges to advocacy efforts
Most notable at press time was the threat to surgical and specialty physician Medicare payment cuts from the U.S. Centers for Medicare & Medicaid Services (CMS) included in the 2021 Medicare physician fee schedule proposed and final rules released August 3 and December 1, 2020. The American College of Surgeons (ACS) Division of Health Policy and Advocacy in Washington, DC, continued to engage Congress on the College’s federal legislative priorities using traditional advocacy methods, such as formal position letters and lobbying, but also it has pivoted to new communications channels, such as virtual meetings and conferences, to connect with surgeons and members of Congress.
Locally, significant challenges exist in this new health and policy environment regarding meeting in person with county and state legislators to advocate for health care issues. In 2020, many state legislatures ended sessions early, rescheduled session dates, or convened short, special sessions on very specific issues, with little notice for advocates to fully organize and engage with legislators.
In addition, in an effort to promote social distancing and control the spread of COVID-19, many legislative district offices closed, eliminating nearly all in-person and face-to-face meetings, including nearly all ACS chapter meetings and advocacy efforts such as surgeon advocacy days at state capitols.
The cancelation of in-person advocacy opportunities raises questions as to how the important work of surgical health policy advocates still can be accomplished and how relationships with important elected officials can be continued, fostered, and built from new.
The shift to virtual meetings
To overcome the challenges of in-person meetings or social distancing requirements, surgeons with the San Diego-Imperial ACS Chapter organized a virtual meeting using Zoom to meet with California state senator and candidate for San Diego Board of Supervisors Ben Hueso in the November 3, 2020, election, which he lost. Despite some initial apprehension with this format, we quickly learned of its many advantages—not unlike other revelations in the use of virtual video communications, including video clinical visits, interviews, and the use of telehealth services for meeting with patients.
Whether it is that natural leadership role that surgeons have or learned traits of control of complexity in the operating room or trauma bay, triage, direction, leadership, and reflection were invaluable attributes through this crisis.
Using a virtual video service, we were able to schedule the meeting much more quickly with a larger group of surgeon participants from a more varied representation of hospital systems. Because no one needed to travel, the senator was able to join the meeting from the state capitol in Sacramento, greatly increasing scheduling options. Furthermore, trauma surgeons from multiple institutions were able to participate from either their hospital office or from home, as scheduling permitted. The ability to meet without finding a venue; spending resources on travel, food, or beverages; and coordinating schedules that would allow time for the travel was a great advantage. The conference still allowed for a natural interaction, which permitted the participants to read both facial expressions and body language.
San Diego has a strong and well-developed county-based trauma system. In November 2020, a long-held position on the County Board of Supervisors (CBS) timed out, with multiple candidates running for the soon-to-be-vacated seat. Because the San Diego trauma system is regulated and partially administered by the CBS, our local chapter reached out to the frontrunner in the race, Senator Hueso, to begin a series of conversations with candidates and future partners. Moreover, because San Diego is an international border city with transfer of patients from and to Mexico, this meeting presented an opportunity to discuss challenges with a member of the state legislature and a potentially influential voice on the county board.
The meeting was initiated by members of the San Diego-Imperial Chapter of the ACS via a chapter member’s existing relationship with Senator Hueso. An invitation for a trauma and surgery listening session was extended to the senator, who responded personally via text. With this direct communication, a date for a Zoom meeting was quickly set with the senator and logistics for the meeting were finalized with his office staff.
Once the meeting was set, we worked to finalize surgeon participants and the topics to be covered in the meeting. Invitations were extended to members of trauma programs from throughout the ACS San Diego-Imperial Chapter region. The coordinating surgeon developed an agenda and circulated it to invited participants for feedback. We decided that the focus of the meeting would be on providing general information related to trauma and emergency general surgery delivery from the county trauma system and discussing how circumstances such as poverty and homelessness affect trauma care, as well as the impact of international border issues on the delivery of care.
Topics addressed during virtual meeting
Seven surgeon members of the San Diego-Imperial Chapter of the ACS met with Senator Hueso for nearly 40 minutes. Key to the meeting’s success was assigning roles to participating surgeons. Following is a summary of the discussion to serve as a case example.
Jay Doucet, MD, FACS, FRCSC, a coauthor of this article and chief, division of trauma, surgical critical care, burns, and acute care surgery; surgical director of perioperative services, Hillcrest; and medical director of emergency preparedness and response, UCSD Health, gave an overview of the San Diego County Trauma System. More specifically, he described the feasibility study funded by the county supervisors in 1982 and creation of the Country Wide Trauma System in 1984 as a collaborative initiative between hospitals and hospital systems in San Diego County.
Todd Costantini, MD, FACS, surgical intensivist, associate professor of surgery, and medical director, trauma, UCSD Health, discussed the significant impact of the ACS STOP THE BLEED® Campaign with placement of bleeding control kits at the San Diego Airport and Convention Center, as well as training for all county employees. Dr. Costantini continues to work to expand this program locally. Statewide legislation has been introduced previously but has been on hold because of COVID-19.
Allison Berndston, MD, FACS, a general surgeon and assistant professor of surgery, UCSD Health, discussed global health care, particularly as it relates to the international border with Mexico, and cooperative interventions between San Diego critical care physicians and hospitals and physicians in Tijuana regarding COVID-19. Further discussion is needed regarding the need for improved communication of health information for all transborder patients. She noted that many opportunities are available to share and provide education for injury prevention and treatment. Senator Hueso asked about work with already established government agencies and identified opportunities for further collaboration in the future.
Because San Diego is an international border city with transfer of patients from and to Mexico, this meeting presented an opportunity to discuss challenges with a member of the state legislature and potentially influential voice on the county board.
Jeanne Lee, MD, FACS, director, UCSD burn center, and professor of surgery, UCSD Health, shared information about the burn center, the only such facility in San Diego County, including the increased severity of average burns seen in 2020. She shared the ongoing problem of severe burns in the U.S. population, particularly among people injured in Mexico and returned to San Diego.
Amy Liepert, MD, FACS, medical director, acute care surgery, and associate professor of surgery, UCSD Health, and coauthor of this article, gave an overview of the complex clinical environment of trauma and acute care surgery in San Diego, including caring for severely injured patients and interfacing with patients of low socioeconomic status, many of whom have advanced surgical disease. She discussed how local community issues affect county, state, federal, and even international policies and, more importantly, patients.
As the UCSD representative on the Coronado Bridge Suicide Deterrent Project, Dr. Liepert also provided a status update on this program, which was created under S.B. 656, a bill passed by the California State Legislature and signed into law September 19, 2019.
Senator Hueso asked a number of questions regarding county funding sources for the trauma system. Participants discussed the successful reduction of mortality rates resulting from a coordinated trauma system, including the unique cooperative features of all hospitals within the system collaborating and meeting to review cases and improve quality. The importance of ACS verification also was discussed.
Senator Hueso expressed appreciation for health care workers during the pandemic and the multitude of ways trauma and acute care surgeons interact with the community to improve health outcomes. He expressed additional interest in building collaborative relationships in the areas of substance abuse and mental health. Both areas greatly affect trauma, burn, and emergency general surgery care, particularly as it relates to chronic homelessness.
Although the meeting took place virtually, with each participant in separate locations and with the senator more than 500 miles away in the state capitol, we found that scheduling and preparing for the meeting was easier than arranging an in-person meeting that requires the parties to travel and to be in the state capitol at the same time. Using technology in grassroots advocacy has the potential to help more surgeons interact with legislative partners even after pandemic social distancing dissipates. Particularly for surgeons with practices at great distance from the state capitol, the use of video conferencing by individuals or groups of all sizes presents an amazing opportunity to enhance advocacy efforts, education, and collaboration in the future.