Surgeon advocacy in action: Challenges, accomplishments, and future direction

The Merriam-Webster Dictionary defines “advocacy” as “pleading or defending a cause with steadfast support.”¹ As surgeons, our responsibility to safeguard patient care is paramount, and that work does not halt as we step outside of the hospital. Surgeon activism at both the state and national levels has benefited patients, and these patient-centered government policies are essential for surgeons to deliver better patient care.

The drive for better patient care has motivated many surgeons in the past, such as Todd Wider, MD. In the 1990s, Dr. Wider, a plastic surgeon in New York, NY, noted that insurance companies did not cover reconstructive operation after mastectomies for breast cancer patients.^2,3 This issue steered Dr. Wider’s quest for political action, which started with the state of New York, and ultimately, culminated with the Women’s Health and Cancer Rights Act in 1998, which mandated insurance coverage for reconstructive surgery postmastectomy.² Further legislation in 2001 placed penalizations on noncompliant insurance companies.⁴

Navigating the policy world for the individual surgeon-advocate can be fraught with obstacles and challenges. Some may find it daunting to undertake the breadth of issues related to surgery. Fortunately, assistance is available for those surgeons interested in engagement. The Advocacy and Issues Committee of the Resident and Associate Society of the American College of Surgeons (RAS-ACS) has many resources to help trainees and young surgeons join forces with other like-minded individuals to effect change. This article explores some of the legislation that surgeons have supported over the years, the present-day issues that require our advocacy efforts, and how individuals can get involved to help make a difference beyond the borders of the operating room.

Successful advocacy efforts and their impact

Consider a scenario: Mr. A arrives at work like any other day. However, as the day progresses, his abdominal pain worsens to the point that it becomes so severe he can barely walk. His coworkers call an ambulance, and he is taken to the local emergency room and is found to have acute appendicitis. You are the surgeon on call, and you see Mr. A and promptly perform a laparoscopic appendectomy. The patient assumes that his health insurance will cover his urgent care. He has met all of his deductibles this year. Three weeks later, he finds a bill in his mail for tens of thousands of dollars because the surgeon and the anesthesiologist are “out of network.”

Patients commonly encounter this scenario in the U.S. During an emergent or urgent situation, the last thing on the surgeon’s mind is surprise billing. Many times, patients will wonder or even ask how much their health crisis will cost them. Often, the only helpful reassurance surgeons can provide patients is that their health comes first, and members of the multidisciplinary team can assist in managing costs. Even with assistance, tremendous costs may be associated with services that are not covered by an insurance plan.

One of the most notable members of the medical community who brought attention to this issue can be found on Twitter. “Dr. Glaucomflecken” (@Dglaucomflecken) chronicled his cardiac arrest and intensive care unit (ICU) stay that was out-of-network and his subsequent battle with his insurance company on social media via Twitter. This public account of events exposed a broader audience to the reality of surprise medical billing. Patients should not be burdened with the possibility of paying exorbitant costs for emergency care, especially when they have performed their due diligence in maintaining their health insurance.

The ACS has worked tirelessly in advocating for transparency of insurance coverage and pricing. Legislation passed in December 2020 mandated that insurance plans cannot add charges to the in-network amount for emergencies when patients cannot choose their provider.⁵ Although this legislation will not take effect until January 2022, it is a great victory for patients and allows for more peace of mind when it comes to medical costs.

Another successful advocacy effort centers on the electronic health record (EHR), which has led to significant fatigue and burnout for some health care providers, even as the EHR has enhanced health care by providing internal checkpoints, preventing prescription errors, and increasing ease of access for both the provider and patient. The ACS began communicating with both the Centers for Medicare & Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology to help improve EHR processes. Several recommendations were made regarding streamlining redundancies, optimizing log-on procedures, enhancing interoperability between varying systems, removing meaningful use obligations for EHR, and allowing for electronic prior authorization capabilities.^6,7 These successful advocacy efforts were evident with the passage of the Bipartisan Budget Act of 2018, which included reducing meaningful use obligations in the EHR and allowing diminution of the administrative burden for surgeons.⁸

There is no shortage of discussion regarding the significant scarcity of U.S. health care professionals. There had not been an increase in the number of federally funded residency slots from 1997 to 2021—nearly 25 years.⁹ The limited number of residency positions has created a bottleneck for newly graduating physicians, denying some graduates the opportunity to pursue further training. In the 2021 match, there was a record-high 48,700 applicants, and 94.9 percent of the 38,106 positions were filled, leaving 10,594 aspiring trainees without a position.¹⁰ The match left behind a large number of qualified medical school graduates, resulting in a great disservice to the hardworking individuals who had completed their medical school training with dreams of becoming practicing physicians.

The ACS supported a bill passed in December 2020 to create 1,000 additional residency positions via Medicare funding.⁵ The new positions will open in the year 2023, focusing on rural locations and areas with shortages of health care providers.⁵ Although this increase will not address all 10,000 applicants without a position this past year, it is a step toward addressing the physician shortage in this country.

In addition to the legislative efforts described earlier, some of the most significant advocacy-related victories for the House of Medicine over the last decade include the defeat of the Medicare sustainable growth rate (SGR) and the defeat of the Independent Payment Advisory Board (IPAB).¹¹ Both the SGR and IPAB were intended to decrease Medicare spending by constraining reimbursement rates. To limit growth in Medicare spending, specifically on physician services, the SGR was designed to trigger automatic and increasingly drastic cuts in Medicare reimbursement over time.¹² The ACS was instrumental in defeating this payment methodology, particularly because fee-for-service payment changes can disproportionately affect surgeons.¹³ The IPAB was a controversial aspect of the Affordable Care Act (ACA). Instead of requiring acts of Congress to change the Medicare payment rates, the ACA would allow the President to appoint a 15-member board that had the full authority to implement changes. The consequences of the implementation of IPAB could have been detrimental, and thus, its defeat was another long-sought goal of the ACS.¹⁴

Often it can be difficult to identify and quantify both who is responsible for successful advocacy efforts and what constitutes a “success.” All advocacy efforts require collaboration with multiple stakeholders, all of which are responsible for and deserving of credit for the outcomes. As Manny Sethi, MD, said, “The success [of advocacy] is illustrated by anecdotes more than scientific evidence.”¹¹ It is important to remember that the victories described in this article would have been impossible without the grassroots work of individual surgeons and the ACS Division of Advocacy and Health Policy (DAHP).

Current issues and the role of surgeon advocacy

The coronavirus 2019 (COVID-19) pandemic created unprecedented challenges for the medical community. In the last year, medical providers have been faced with shortages in personnel and personal protective equipment (PPE), rapid changes in hospital policies, delays in surgical care, disruptions to surgical education and research, financial obstacles, and the emotional toll of redeployment to provide critical care during the pandemic. Throughout this time, surgeons have played a key role in advocating for both providers and patients to deliver and regulate high-quality surgical care.

At the beginning of the pandemic, national shortages of PPE resulted in significant challenges for health care providers on the front lines. Although the recommendations called for physical distancing, frequent hand hygiene, eye protection, and well-fitted masks during patient encounters, many health care systems were unable to provide adequate PPE to their workforce.^15,16 Because protection of the workforce is vital for any pandemic relief effort, surgeon advocacy was critical during this period. In November 2020, leaders from the ACS, the American Society of Anesthesiologists, and the Association of periOperative Registered Nurses drafted a letter to political leaders urging them to continue to aid in the distribution of equipment and supplies, specifically PPE and the drugs necessary in the ICU settings.¹⁷ In addition, this letter focused on health care workers’ emotional well-being resulting from significant staffing shortages as providers experienced burnout or contracted illness. Such efforts helped raise awareness, leading to national efforts to increase federal assistance to hospitals during this period of the pandemic.

In addition to advocacy efforts to ensure provider safety during the pandemic, the development of resource and human capital allocation guidelines has been equally challenging. Elective procedures were postponed to aid in staff and resource redeployment during the initial phases of the pandemic. Triaging case volume during this period was necessary for multiple reasons, including PPE and staff shortages, hospital and ICU bed availability, and social-distancing guidelines. Surgeons played a unique role in these discussions, as often they were in positions to advocate for procedures for their patients. Surgical societies were tasked with defining elective surgery and proposing guidelines for the de-escalation of surgical care. For example, the Society of Surgical Oncology (SSO) surveyed the SSO disease site work group chairs and vice-chairs to generate consensus guidelines on the management of cancer surgery during the COVID-19 pandemic.¹⁸ Despite these guidelines, individual surgeons often were tasked with making treatment decisions on a patient-by-patient basis. As case volume recuperates with the improvements in PPE and testing, surgeons must now pivot and lead efforts to prioritize the elective cases that were delayed. Similarly, appropriate triage of patients who may not have presented for surgical care during the pandemic must be developed. While the full effect of the pandemic on surgical disease and oncologic outcomes remains unknown, surgeons will likely continue to play a role in appropriately selecting patients for surgery in resource-limited settings.

Since 2013, a 2 percent yearly Medicare payment reduction has been looming as part of the Budget Control Act of 2011. Medicare budget reductions are made as “sequester” cuts—a predetermined percentage in budget reduction that was initially developed as a tool to help control federal spending. While these decreases were originally slated to finish in 2022, their new end date is 2030 because of the CARES (Coronavirus Aid, Relief, and Economic Security) Act.¹⁹ Over the years, hospitals have offset expenses by cost-shifting and reducing overall operating expenses. The downstream effects of these compensatory strategies have led to reduced staffing, increased pressure to reduce the length of stay, and scaled-back investment in newer technologies.²⁰ The long-term implications that these reductions will have on patient care remain to be seen. However, Shen and colleagues showed that hospitals subjected to more considerable payment reductions had worse improvement in inpatient mortality rates than their counterparts that had smaller reductions.²¹

Unsurprisingly, the effect of Medicare payment cuts on physician reimbursement and patient care has been a continued topic of interest to multiple physician groups. Furthermore, some of these cuts have disproportionately affected surgical specialties. Haglin and colleagues estimated that the reimbursement rate for the 20 most common general surgery Current Procedural Terminology codes would drop an average of 1.4 percent annually. In addition, CMS’ 2021 Medicare physician fee schedule reduced payments by up to 9 percent for some surgical subspecialties, including cardiac, thoracic, vascular, neurosurgery, and ophthalmology.²² The 9 percent cuts were averted, for this year at least, through legislation passed at the end of 2020, which the ACS-led Surgical Care Coalition strongly advocated for.

This year, the COVID-19 pandemic has further complicated this issue. In addition to the yearly 2 percent sequestration cut, the Pay-As-You-Go Act, enacted as part of the COVID relief bill, has triggered an additional 4 percent sequestration cut to Medicare for this year. Though our health care system has adjusted to Medicare cuts previously, COVID-19 has placed increased stress on hospitals and their resources.²⁰ Consequently, many hospitals are facing bankruptcy, and thousands of patients may be left without reliable care.²³ The American Medical Association and the ACS both released statements that criticize the enactment of these cuts during the pandemic.^24,25 As a result, these cuts have been delayed through the end of 2021. Unfortunately, the bill also specifies a required increase in sequester cuts in the year 2030.²⁶ Continued advocacy is vital as our understanding of the effects of the COVID-19 pandemic on how our health care system evolves.

Tools and resources for resident advocates

Surgeon advocacy is a topic that can be foreign and daunting to many of our colleagues. The rigorous training required to become a board-certified surgeon does not include a thorough understanding of the legislative process or health care policy. The ACS provides a strong foundation for advocacy efforts via the DAHP. For residents, the RAS-ACS Advocacy and Issues Committee is an invaluable resource that allows residents to become more informed and involved. The objectives of this committee are to address issues in resident training and health care policy and promote resident engagement in advocacy at the local and national levels.

The ACS Leadership & Advocacy Summit, offered annually in Washington, DC, allows surgeons to put advocacy into action. Each year, the College prioritizes key pieces of legislation, and attendees discuss these priorities with their legislators. Resident participation in the summit is supported and encouraged. Each year, the ACS provides a number of scholarships to resident members who apply to attend the conference. Resident-focused events, such as the Leadership Development Workshop, provide an opportunity for residents to hear from surgical leaders on various topics related to leadership in surgery. For the Advocacy portion of the meeting, the RAS hosts a breakfast for resident attendees, where staff from the ACS DAHP prepare residents for Capitol Hill visits. Attending the meeting not only gives residents an opportunity to get involved with advocacy on the Hill, but also opens the door for meeting other resident members. This networking opportunity is invaluable in developing relationships that evolve into future RAS projects.

The RAS Advocacy and Issues Committee offers residents the opportunity to advocate for themselves, their patients, and the future of health care. This advocacy work doesn’t always involve direct political action. For example, a subcommittee recently published an article on opioid prescribing habits among residents.²⁷ The goal was to highlight the importance of using current data to guide resident education on opioid prescribing in order to appropriately manage postoperative pain and to limit the number of excess opioids that are available for diversion and inappropriate use.

The RAS-ACS COVID-19 Resident Task Force is another important advocacy effort for residents. This project was born from anecdotal reports of resident experiences during the pandemic. The committee members surveyed RAS members about access to PPE and the effect of the pandemic on the resident experience, including surgical education and burnout. The results of this survey were published in the Journal of the American College of Surgeons and showed a decrease in operative volume, inability to meet case requirements, inadequate access to PPE, and increased burnout as a result of the pandemic.²⁸ The task force is using these data to determine what steps can be taken to help support and protect residents in the future.

In addition to advocacy for surgical residents, the podcast Arming with Knowledge: Building the Culture of Firearm Safety and Injury Prevention was created by RAS members in an effort to advocate for patients. The objective of this podcast is to discuss the issue of firearm safety in the U.S., the common narrative that allows surgeons to unite in addressing this issue, and how we can help prevent injury and death as a result of firearms.

The RAS Symposium is another important sounding board for discussing issues related to surgical residents and resident education. Hosted by the Advocacy and Issues Committee each year at the ACS Clinical Congress, this event serves as a prime focus of the committee’s efforts annually. Each year, the committee selects a salient topic, hosts an essay contest for resident members to submit essays on the “pro” or “con” side, and organizes the symposium where essay contest winners and invited speakers discuss both sides of the topic. In previous years, topics have included resident unionization, the role of advanced practice providers and their effects on resident education, and shift work in surgery. This year’s topic will discuss competency-based training in surgical residency (see related article).

Conclusion

For many decades, the ACS has led efforts to advocate for surgeons across all specialties as well as for patients. As some say, “If you are not on the table, you are on the menu.” The laissez-faire approach to the legislative and regulatory issues affecting surgical care will not only hurt surgeons but also their patients. We have a vested interest in ensuring that our patients are protected, and that other interest groups’ agendas that may not align with the well-being of our patients do not prevail. We have made significant strides on several issues, but more work needs to be done.

The COVID-19 pandemic has had significant effects on many practices across the U.S. Fair compensation is being threatened as concern about rising health care costs increases. Many patients across the country are still having difficulty navigating their care. Despite doing everything in their power, they find themselves in unfortunate situations with significant debt, causing financial and psychological burdens.

What are the next steps to make a difference as a surgeon? Where can one start? First, start with your peers at the ACS. At the annual Leadership & Advocacy Summit, you will find like-minded peers who want to learn more and be more involved in advocacy. Donate to the ACS Professional Association-SurgeonsPAC and help with the efforts of the ACS in advocating for issues that affect all surgeons. Most importantly, engage with your elected officials. Write, call, or e-mail your representative or senator. Lawmakers want to hear from constituents like you, who are respected members of society and subject matter experts. The more individuals who join in a unified voice, the bigger the impact our advocacy efforts have on those who are listening.

References

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