Data Reveal the Details about the Surgeon Workforce Shortage

Increasing evidence indicates an ongoing shortage of surgeons available in the US to serve our nation’s patient population. A shortage of general surgeons is a critical component of the crisis in the healthcare workforce because only surgeons are uniquely trained and qualified to provide certain necessary, lifesaving procedures.

In light of growing evidence demonstrating a shortage of general surgeons, the American College of Surgeons (ACS) has determined that more accurate and actionable workforce data are necessary to determine exactly what constitutes a surgical shortage area and where these areas exist.

Understanding the Problem

In areas without general surgeons or with an insufficient surgical workforce, patients in need of care must travel to a location with surgical capabilities, leading to delays in care and potentially suboptimal outcomes. Access to local general surgeons averts the need for transfer, time away from employment, travel, and associated costs.

In addition to improving care and outcomes for patients, a general surgeon contributes substantially to the local economy, both in terms of hospital revenue and creation of jobs, which are critical to the hospital and the community it serves.¹ Loss of surgical services and their associated revenues can contribute to hospital closures, which can be catastrophic to the local community.² The loss of surgical services and hospital closures is felt acutely as more than 100 rural hospitals closed between January 2013 and February 2020.³ A February 2021 report from the Center for Healthcare Quality and Payment Reform found the coronavirus pandemic has increased the number of rural hospitals at immediate risk of closure to 500, with an additional 300 at heightened risk of closure in the near future.⁴

A congressionally mandated 2020 report conducted by the Health Resources and Services Administration (HRSA) detailed potential surgical shortages, especially as related to geographic location (that is, rural, urban, and suburban).⁵ Specifically, the report found a maldistribution of the surgical workforce, with widespread and critical shortages of general surgeons, particularly in rural areas. In addition, a 2021 report released by the Association of American Medical Colleges projects shortages of 15,800–30,200 surgeons by 2034, an increase from previous estimates.⁶

Surgical Workforce Data Collection Is Needed

The ACS maintains that building a solid foundation of accurate and actionable data is critical to better understand the physician workforce and identify and define general surgery shortage areas.

At present, our healthcare system is in dire need of accurate data. The ACS asserts that the periodic, repetitive collection and analysis of workforce data on both a regional and national basis should be a top priority for government agencies, particularly at the federal and state levels. This data collection should be undertaken in consultation with relevant stakeholders to ensure accuracy of both the data collected and its subsequent analysis. Data collection is necessary in order to better understand the healthcare workforce supply and distribution and project workforce demands for the future.

Unfortunately, these data do not tell us if the supply of all surgical specialists nationwide is adequate to provide access to the surgical services, largely because there is no agreed-upon definition of what constitutes a shortage of general surgeons for a given population. Because there is no federally accepted definition of a surgical shortage, projections reset annually and assume that the then-current ratio of surgeons to population is the appropriate baseline rather than tracking the decline in the workforce over time. The data simply tell us that year after year we are falling behind, with a shrinking proportion of general surgeons to population. In preparation for future surgical workforce demands, the College encourages Congress to support the comprehensive, impartial research and high-quality data needed to form dynamic healthcare workforce projections.

Improving Access to Surgical Care

Reforms aimed at strengthening the workforce must account for the disparities that exist in accessing surgical care. Access to care is affected by socioeconomic status, age, gender, level of education, race, ethnicity, healthcare availability, and geographic distance, among other factors. Timely access to surgical care is necessary for optimal outcomes. Efforts to increase surgical presence and availability are crucial to providing the right care, at the right time, in the right place.

Optimal quality, the cornerstone of the ACS, can be achieved if patients have equitable access to care. A January 2021 study found that older cancer patients are less likely to have optimal results following a cancer operation if they live in an area highly affected by social challenges, especially if they are minorities.⁷ Another study published in January 2021 of liver transplant centers confirms that non-Hispanic White patients get placed on liver transplant wait-lists at disproportionately higher rates than non-Hispanic Black patients.⁸ The one key step to achieving the ACS motto, “To heal all with skill and trust,” is providing high-quality care to all and eliminating racial disparities in access to care.

What Congress Can Do

To help ensure improved accuracy in workforce data collection and analysis, the College supports the following legislative options that Congress should consider.

Develop a Geographic Shortage Area Designation for Surgery

Unfortunately, HRSA does not have the authority to designate a geographic shortage area for general surgery. Determining what constitutes a surgical shortage and designating areas where patients lack access to surgical services would provide HRSA with a valuable new tool for increasing access to the full spectrum of healthcare services. Identifying communities with workforce shortages is a critical first step in guaranteeing all patients, regardless of geographic location, access to quality surgical care. Only then can necessary actions be taken to address these shortages and disparities in access to care.

As part of a multipronged effort to address workforce shortages, the ACS successfully secured language in the fiscal year 2019 appropriations bill that directed the US Department of Health and Human Services (HHS), via HRSA, to study access to general surgeons among underserved populations. In addition to the study, the language directed HRSA to provide a report detailing potential surgical shortages, especially as it relates to geographic location.

This congressionally mandated report released in 2020 found a maldistribution of the surgical workforce, with widespread and critical shortages of general surgeons, particularly in rural areas. The ACS maintains that these data highlight an urgent need to establish a surgical shortage designation, which would allow for better resource allocation and incentives to practice in areas that have too few general surgeons.

To build upon existing data and plan for the future, the ACS supports the Ensuring Access to General Surgery Act of 2021 (S. 1593/H.R. 5149), reintroduced by Sens. Brian Schatz (D-HI) and John Barrasso, MD (R-WY), and Reps. Ami Bera, MD (D-CA), and Larry Bucshon, MD (R-IN). The legislation would direct the Secretary of HHS, through HRSA, to study and define general surgery workforce shortage areas and collect data on the adequacy of access to surgical services. In addition, the legislation would grant the Secretary of HHS the authority to designate general surgery shortage areas.

Reauthorize the HSIP Program

The Affordable Care Act created a Medicare incentive payment program for major operations provided in health professional shortage areas (HPSAs) to increase and improve access to high-quality surgical care in rural and underserved areas. This initiative, called the HPSA Surgical Incentive Payment (HSIP) program, provided a payment incentive to surgeons who performed major operations—defined as those with a 10-day or 90-day global period under the Medicare Physician Fee Schedule—in a HPSA. HPSAs, designated by HRSA, are geographic areas that lack sufficient numbers of physicians to meet the healthcare needs of an area or population. The HSIP program expired in 2015.

The ACS urges Congress to reauthorize the HSIP Program for a period of 5 years so that general surgeons, who are a key element of rural, frontline care and who have been among the hardest hit by the COVID-19 pandemic, would receive the additional support needed to continue serving rural communities.

GME Funding Reform

The ACS maintains that broad reforms to the way in which graduate medical education (GME) is funded and administered are long overdue and necessary to ensure that training centers are able to produce a physician workforce capable of meeting the needs of our nation’s population. The ACS advocates for solutions that are flexible, nimble, patient-centric, and, most importantly, evidence-based.

To preserve the innovation and excellence for which our country’s medical system is known, GME should continue to be supported as a public good. The ACS has developed a set of principles on GME reform and used them to formulate a policy and position paper. These principles and white paper will be used to advocate for reforms that are based on documented workforce studies and will result in building and sustaining an optimal healthcare workforce.

The ACS supports the Resident Physician Shortage Reduction Act (S. 834/H.R. 2256), introduced by Sens. Robert Menendez (D-NJ), John Boozman (R-AR), and Chuck Schumer (D-NY), and Reps. Terri Sewell (D-AL), John Katko (R-NY), Tom Suozzi (D-NY), and Rodney Davis (R-IL). This legislation seeks to bolster the US surgical workforce and healthcare infrastructure by increasing the number of Medicare-supported residency positions nationally by 2,000 each year from 2023 through 2029 for a total of 14,000 slots.

The ACS remains dedicated to working with Congress to further address the surgical workforce issues facing our nation. To learn more about congressional efforts to address surgical workforce issues, visit facs.org/advocacy.

References

1. Eilrich FC, Sprague JC, Whitacre BE, Brooks L, Doeksen GA, St. Clair CF. The economic impact of a rural general surgeon and the model for forecasting need. National Center for Rural Health Works. September 2010. Available at: http://digitalprairie.ok.gov/cdm/ref/collection/stgovpub/id/24192. Accessed December 10, 2021.
2. Ellison A. The rural hospital closure crisis: 15 key findings and trends. February 11, 2016. Becker’s Hospital CFO Report. Available at: https://www.beckershospitalreview.com/finance/the-rural-hospital-closure-crisis-15-key-findings-and-trends.html. Accessed December 10, 2021.
3. US Government Accountability Office. Rural hospital closures: Affected residents had reduced access to healthcare services. January 21, 2021. Available at: https://www.gao.gov/products/gao-21-93. Accessed December 10, 2021.
4. Nelson H. COVID-19 increases rural hospital closure risk, care access concern. Practice Management News. February 3, 2021. Available at: https://revcycleintelligence.com/news/covid-19-increases-rural-hospital-closure-risk-care-access-concern. Accessed December 10, 2021.
5. US Department of Health and Human Services. Health Resources and Services Administration. Report to the Senate Committee on Appropriations. 2018. Available at: https://www.facs.org/-/media/files/advocacy/federal/hrsa-general-surgeon-projection-report-to-appropriations.ashx. Accessed December 10, 2021.
6. Association of American Medical Colleges. The Complexities of Physician Supply and Demand: Projections from 2018 to 2033. June 2020. Available at: https://www.aamc.org/media/45976/download. Accessed December 10, 2021.
7. Hyer JM, Tsilimigras DI, Diaz A, et al. High social vulnerability is associated with a decreased chance to achieve a “textbook outcome” following cancer surgery. J Am Coll Surg. 2021;232(4):351-359.
8. Warren C, Carpenter AM, Neal D, et al. Racial disparity in liver transplantation listing. J Am Coll Surg. 2021;232(4):526-534.