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ACS Response to Major Categories of Concerns2006 Board of Governors SurveyValerie W. Rusch, MD, FACS 2007 Board of Governors Survey Response Slides (15K PDF)
Professional liability/malpractice/tort reform and risk management/patient safety
Graduate medical education (GME)
Pay for performance/competency measurement for practicing surgeon
Physician reimbursementCongress blocks 2007 Medicare cut and establishes bonus payments On December 20, the president signed into law HR 6111, the Tax Relief and Health Care Act of 2006 (PubL 109-432), which included provisions to block the five percent cut in the physician fee schedule conversion factor that was scheduled to take effect on January 1, 2007. On December 11, Thomas Russell, MD, FACS, sent an electronic special alert to Fellows with an update on the House and Senate passage of the Medicare relief package and the president’s anticipated signature on HR 6111. This was followed by a “Dear Colleague” letter that was mailed to all US Fellows in early January. PubL 109-432 froze the 2007 conversion factor at $37.8975. While the bill effectively halted the cut, this freeze took the form of a five percent "bonus" adjustment to the conversion factor, meaning that, technically, the five percentage point reduction still occurs in 2007. Consequently, when the 2007 adjustment expires at the end of the year, calculation of the 2008 conversion factor will begin with the lower number (about $35.98) that would have taken effect in 2007 had Congress failed to intervene. As a result, the combined impact will be an estimated 10 percent reduction in the conversion factor for 2008 unless Congress acts once again. In addition, the new law establishes a "pay-for-reporting" incentive program. Between July 1 and December 31, physicians who report specific quality measures on Medicare claim forms for a sufficient number of eligible services will receive a 1.5 percent bonus payment for all covered Medicare services. The Centers for Medicare and Medicaid Services (CMS) plans to use refined versions of the measures developed through the Physician Voluntary Reporting Program (PVRP) and approved by AQA; and the 1.5 percent bonus will be paid as a lump sum early in 2008 to each reporting physician who qualifies. Finally, the law restores for one year the expiring “floor” on geographic adjustments made to physician payments under the fee schedule, which benefits physicians in rural areas. CMS issues proposed rule on ambulatory surgery center payments In November, the College submitted comments on the 2008 ambulatory surgery center (ASC) payment rule> The rule is divided into two main sections--the ASC procedure list and the ASC payment rates. Currently, Medicare will only pay for procedures performed in an ASC if they are on the ASC procedure list. In the rule, CMS proposed making the ASC list an “exclusionary” list instead of an “inclusionary” list, meaning that a procedure can be done in an ASC unless it is on the list and so specifically excluded. The College has called for this change for several years. However, in the rule, CMS used the same criteria to exclude procedures as it did to include procedures; therefore, roughly the same procedures that were included are now excluded. The large majority of those procedures that actually changed reimbursement status are those that are predominately performed in physician offices. In its comments, the College questioned the criteria used to exclude procedures and argued against the use of blanket rules because the very idea of an exclusionary list implies that procedures are excluded because they have been reviewed on their merits and were found to be unsafe. On the payment side, the rule proposed paying 62 percent of the Hospital Outpatient Prospective Payment System (HOPPS) rate for all ASC procedures. Some procedures, including many gastroenterology, ophthalmologic, and colon and rectal procedures are currently paid at a much higher rate while others, including many orthopaedic, neurosurgical, and general surgery procedures are currently paid less than 62 percent. The primary reason for the 62 percent figure is because, under law, the changes to the ASC payment system must be budget neutral. The College’s comments on the ASC rate setting method focused on the methods used to determine the conversion factor, yearly inflation update, and the packaging and bundling of certain supplies and drugs. College supports ASC legislation Introduced by Reps. Kendrick Meek (D-FL) and Wally Herger (R-CA), HR 1823, the Ambulatory Surgical Center Payment Modernization Act of 2007, would provide a more equitable payment system for ASCS and follows a Medicare Payment Advisory Commission (MedPAC) recommendation to modify the ASC procedures list. In a proposed rule issued by CMS, payments would be made to ASCs at only 62 percent of the 2008 HOPPS proposed rate. Instead, HR 1823 would provide a more equitable payment rate of 75 percent of the HOPPS. In addition, the bill would allow payments to ASCs for any surgical service, except for those procedures where (1) the Health and Human Services (HHS) Secretary identifies a specific risk concerning a certain procedure being performed in an ambulatory surgery setting, or (2) an overnight stay is required. Under the current rules, CMS arbitrarily adds to and deletes procedures from the ASC list and beneficiaries are routinely denied the option of selecting the ASC for hundreds of procedures that are commonly furnished, safely and effectively, to private-pay patients in ASCs. ACS hosts Congressional briefing on MedPAC reports In conjunction with the release of MedPAC's reports, the College hosted a briefing on March 1 for press and Congressional staff about the challenges already facing surgery under Medicare and the potential impact of MedPAC’s recommendations on surgical care in the future. The speakers included Dr. Russell, ACS consultant Tom Ault, and ACS staff. The briefing provided an overview of the Medicare physician payment system and presented historical data on trends in surgical payment and workforce issues. The briefing also outlined an alternative proposal endorsed by the College and the American Osteopathic Association (AOA), in which service-specific expenditure targets could replace the current sustainable growth rate (SGR) system if Congress is unwilling to provide the estimated $265 billion that would be required to eliminate expenditure targets entirely. House of Representatives passes Medicare physician payment bill On August 1, the House of Representatives passed the Children’s Health and Medicare Protection Act (CHAMP Act), HR 3162, by a vote of 225 to 204. This legislation would reauthorize the State Children’s Health Insurance Program (SCHIP) and replace projected Medicare physician payment cuts in 2008 and 2009 with positive payment updates of 0.5 percent in both years. In addition, the legislation takes steps toward long-range Medicare payment system reforms by replacing the SGR with a new system of six separate expenditure targets and fee schedule conversion factors for various categories of physician services: primary care, other evaluation and management services, imaging, anesthesia, major procedures, and minor procedures. The proposed new expenditure targets and conversion factors are consistent with a proposal that the ACS and the AOA have advocated. This new methodology holds promise of ending the current problem of across-the-board payment reductions being imposed on service categories, such as major procedures, that have experienced relatively low levels of volume and spending growth. These and other provisions would be financed through a tobacco tax increase of 45 cents and a five-year phase-out of overpayments made to Medicare Advantage plans. Many changes in the legislation are anticipated when a House-Senate conference committee meets, however, because the Senate version of the SCHIP reauthorization contains no Medicare payment provisions. Furthermore, President Bush has threatened to veto the legislation due to cost and policy concerns regarding both bills’ proposed expansion of SCHIP benefits. Professional liability/malpractice/tort reform and risk managementMalpractice insurance premiums continued skyward in many places, making mal-practice one of the top issues for surgeons. The College has continued efforts to pass federal medical liability reform this year. A College staff member chaired the Health Coalition on Liability and Access (HCLA), a coalition of more than 75 organizations that support federal medical liability reform. Public education efforts continue The American College of Surgeons Professional Association (ACSPA) is continuing its membership in Doctors for Medical Liability Reform (DMLR), a coalition that is using public relations activities to highlight the importance of this issue to certain senators in states across the country. College active in efforts to pass state reforms The College was active in a variety of efforts to pass medical liability reform at the state level during the past year. Health care reformCollege supports "Principles for Reform of the U. S. Health Care System" Since November 1, 2004, representatives (one elected leader and one staff person) from 11 physician organizations have held three health reform policy summits with the goal of developing consensus on approaches that might lead to health care coverage for all, control of exploding health care costs, and make sensible adjustments to the nation’s medical justice system. In addition to the College, participating organizations included: the American Medical Association (AMA), American Academy of Family Physicians, American Academy of Orthopaedic Surgeons, American Academy of Pediatrics (AAP), American College of Cardiology, American College of Emergency Physicians, American College of Obstetricians and Gynecologists, American College of Physicians, American Osteopathic Family Physicians, and AOA. Ten of the 11 participating organizations (all except the AAP) approved the following set of “Principles for Reform of the U.S. Health Care System,” which were officially released on January 11: PREAMBLE: Health care coverage for all is needed to facilitate access to quality health care, which will in turn in improve the individual and collective health of society.
The College supports the Health Partnership Act Introduced on January 17 by Sens. Jeff Bingaman (D-NM) and George Voinovich (R-OH) and by Reps. Tom Price, MD, FACS (R-GA), Tammy Baldwin (D-WI), and John Tierney (D-MA), S 325 and HR 506, the Health Partnership Act, would authorize grants to states, regional entities, and others to pursue innovative strategies to increase health insurance coverage, ensure patients receive high quality and appropriate care, improve the efficiency of health spending, and use information technology to improve infrastructure. After submitting an application to the bipartisan “State Health Innovation Commission” that would be established, the Commission would approve a variety of reform options, including tax credits approaches, expansion of Medicaid or SCHIP, creation of pooling arrangements, single payer systems, health savings accounts, or a combination of these or other options. Graduate medical educationCollege supports legislation The College supported the Higher Education Affordability and Equity Act of 2007 (HR 1407). This legislation would make student loan interest fully tax-deductible (currently only deductable up to $2,500) and raise the income threshold for taking the deduction to $115,000 for an individual ($230,000 for joint filers). It would allow tax-free treatment of scholarships including room and board. It would also increase the allowed contribution to education savings accounts from $2,000 to $5,000 per year. In addition, the College supported the Medical Education Affordability Act of 2007 (S 1066). This legislation would provide some much needed relief by allowing young surgeons who qualify for the Economic Hardship Deferment to utilize this option beyond the current limit of three years into residency, making surgical careers more accessible. This bill will assure that surgical residents will not be forced to begin repaying their loans during residency or put their loans into forbearance, options that have become very expensive as the interest on these loans rapidly accrues. Pay-for-performance/competency measurement for the practicing surgeonACS perioperative care measure set approved by the AQA The AQA (formerly called the Ambulatory Care Quality Alliance) is a multi-stakeholder group tasked with approval of physician-level performance measures for use by the government and private payers. Its goal is to reduce the workload of measure submission for all physicians by endorsing common sets of performance measures, providing a means to aggregate data across all providers and payers, and establishing a responsible and feasible means for public reporting. Dr. Russell serves on the AQA Steering Committee and Frank Opelka, MD, FACS, serves as chair of the AQA Surgery/Procedures Workgroup. Early this year, the AQA voted to approve the Perioperative Care Measure Set (PCMS), which was sponsored by the College in collaboration with the Surgical Quality Alliance (SQA). The set consists of six measures in the areas of prophylactic antibiotic timing, selection, and discontinuation, and venous thromboembolism prophylaxis. The AQA adopted 31 quality measures for practitioners in 25 surgical and medical specialties at the meeting, bringing the total number of AQA-adopted measures to 80. Other measure sets includes primary care, cardiology, thoracic surgery, eye care, and dermatology. Physician Quality Reporting Initiative (PQRI) begins July 1 In December 2006, Congress passed legislation linking a 1.5 percent Medicare physician payment bonus to reporting Medicare quality data through the PRQI, an updated version of the PVRR. In summary, the PQRI works as follows:
Seventy-four physician performance measures are available for use in the PQRI, all of which were developed with physician involvement. Physicians who report on three performance measures for at least 80 percent of relevant procedures are eligible for the full 1.5 percent bonus payment. Understanding that not all physicians would have three relevant procedures in the list of 74, Congress and CMS allowed some flexibility. If only one or two measures are applicable to a physician’s practice, he or she must only meet the 80 percent reporting rate on those applicable measures to qualify for the full update. In addition, for physicians who report more than four performance measures, CMS will choose the three measures with the highest reporting rate to calculate the bonus payment. Additional information on the PQRI, including performance measure specifications, can be found on the CMS Web site at http://www.cms.hhs.gov/pqri or on the College’s Web site at http://www.facs.org/ahp/pqri. ACS launches PQRI project The College has recruited 34 surgical practices to participate in a project that will collect information on their experiences under PQRI. The purpose of the program is to improve the College’s effort to educate all its Fellows about PQRI requirements and operations, as well as to inform our advocacy efforts as this and other public and private sector quality reporting programs are developed. Future Medicare pay-for-reporting programs The ACS led Surgical Quality Alliance (SQA) continues to investigate how to facilitate clinical quality data reporting through registries and is exploring whether all surgical registries should report into a single warehouse where quality analytics would be performed and reports prepared. This effort is being undertaken in response to a Congressional reference to the use of registries in the 2008 PQRI and Medicare's desire to have a single method of data submission via registries. The use of registries improve the quality of the information available to Medicare and private payers and reduce the burden on physicians and staff by using a single data collection stream for multiple efforts including internal quality improvement, public and private quality initiatives, and maintenance of certification. ACS perioperative care performance measures progress The PCMS, sponsored by the College in collaboration with the SQA, consists of six physician measures in the areas of prophylactic antibiotic timing, selection, and discontinuation, as well as venous thromboembolism (VTE) prophylaxis. The performance measures were developed under a contract between CMS, AMA’s Physician Consortium for Performance Improvement (PCPI), the National Committee for Quality Assurance, and Mathematica, Inc. On January 30, the National Quality Forum (NQF) Steering Committee on Consensus Standards for Hospital Care approved the College’s VTE measure, and the five measures aimed at reducing surgical site infections were approved on April 3. The entire measure set has gone through the NQF public comment process and is now in the NQF member voting process. The measures were previously approved in October 2006 by the PCPI and AQA, a multi-stakeholder alliance concerned with the implementation of quality measures. In addition, the measures have been adopted by CMS for use in the PQRI. SQA Patient Experience Workgroup begins project The SQA convened a group of interested surgical specialties in a Patient Experience Workgroup to examine current patient satisfaction surveys for their relevance to surgical care and to determine the parameters of a surgical survey. The workgroup concluded that there is a need for a surgery-focused patient experience survey and that any instrument developed should be applicable across all surgical specialties and settings. Consumer Assessments of Health Providers and Systems (CAHPS) survey instruments are a family of reporting tools designed to measure quality from the patient’s perspective. Over the past decade, they have been developed through government funded grants and contracts and have evolved into an industry standard for assessing patient satisfaction with health plans and hospitals. CAHPS surveys are used in health systems that cover more than 150 million patients and they currently exist or are being developed in the following areas: health plan, clinician and group, ECHO (behavioral health), dental, American Indian, home health care, children with chronic conditions, people with mobility impairments, health literacy, health information technology, hospital, in-Center hemodialysis, and nursing home. A request for proposals for developing a surgical patient satisfaction survey instrument will be released in mid-May, with plans to award a contract by July 1. The project will be completed by January 1, 2008. The College will serve as the project leader for this endeavor, but all surgical and anesthesia specialties are being encouraged to participate and financial support is being sought from private health insurance plans. After the survey is developed, it will be submitted to the Agency for Healthcare Research and Quality (AHRQ) for endorsement as an official CAHPS survey. Upon approval, it will be the only CAHPS survey instrument for surgical care and will be publicly available. CAHPS surveys are not proprietary and can be used by anyone interested in measuring patient experience. ACS briefs physician members of Congress on ACS quality and safety efforts On February 28, Dr. Opelka briefed members of the Medical and Dental Doctors in Congress Caucus regarding the College’s efforts in quality improvement and patient safety. The briefing was the result of conversations between ACS President-Elect Gerald B. Healy, MD, FACS, and Rep. Tom Price, MD, FACS, (R-GA). Rep. Price initiated the planning of the briefing with Rep. Phi Gingrey, MD, (R-GA), who co-chairs the Caucus with Rep. Vic Snyder (D-AR). Members of Congress present at the briefing included Reps. Price, Gingrey, and Snyder, as well as Rep. Charles Boustany, MD, FACS, (R-LA), Rep. Donna Christian-Christensen, MD, (D-VI), and Rep. Michael Burgess, MD, (R-TX). Workforce issuesCollege-sponsored Institute of Medicine (IOM) capstone event highlights report findings On December 11, 2006, the IOM held its fourth and final nationwide dissemination workshop in Washington, DC, bringing national attention to the findings of three IOM reports on the future of the nation’s emergency care system: 1) Hospital-Based Emergency Care: At the Breaking Point; 2) Emergency Medical Services: At the Crossroads; and 3) Emergency Care for Children: Growing Pains. A. Brent Eastman, MD, FACS, served on the IOM committee and opened the event by challenging political leaders and the medical community to heed warnings found in the reports and follow its recommendations as a blueprint for creating a regionalized, coordinated, and accountable emergency and trauma care system in the US. Edward E. Cornwell, III, MD, FACS, represented the ACS at the workshop. Other Fellows present included Michael F. Rotondo, MD, FACS, Alex Valadka, MD, FACS, and C. William Schwab, MD, FACS. The capstone event provided an opportunity for the College and other stakeholders to engage Congressional and national policy leaders on how best to move forward with implementing the IOM report recommendations. The College’s report released in June, “A Growing Crisis in Patient Access to Emergency Surgical Care,” was distributed to attendees and provided further detail on many of the same conclusions outlined in the IOM reports, particularly with respect to declining access to surgical specialty care in emergency departments. The College will be working with surgical specialty groups to develop and implement a federal legislative and regulatory agenda during the 110th Congress to help alleviate the emergency care workforce crisis. Surgery develops a legislative agenda for the 110th Congress The College, along with the American Association of Neurological Surgeons and the American Academy of Orthopaedic Surgeons, developed a legislative agenda to address the ongoing surgical workforce crisis in emergency departments across the nation. The following priority issues were identified: liability protections, reimbursement for treating the uninsured, loan deferment extension, and the regionalization of emergency care. We are now approaching other surgical specialty societies for input and support and will then enlist a member of Congress to sponsor this agenda. ACS supports tax deduction for uncompensated emergency services On February 28, Rep. Mary Bono (R-CA) introduced HR 1233, the Mitigating the Impact of Uncompensated Service and Time Act of 2007. Introduced to help alleviate the financial burden placed on physicians who are federally mandated to provide emergency care, this legislation would amend the Internal Revenue Code of 1986 to allow them to partially offset the cost of providing uncompensated care that is required under the Emergency Medical Treatment and Labor Act. Board certified physicians providing these services could take a tax deduction equal to the Medicare fee schedule payment. College supports emergency medical services bill Introduced by Reps. Bart Gordon (D-TN) and Pete Sessions (R-TX) and by Sens. Debbie Stabenow (D-MI) and Arlen Specter (R-PA), HR 882 and S 1003, the Access to Emergency Medical Services Act of 2007, would establish a commission to examine factors, such as emergency department overcrowding, the availability of on-call physicians, and medical liability issues, that can interfere with patients receiving high-quality emergency care services. The bill would also provide a 10 percent bonus payment for services provided to Medicare beneficiaries who present through the emergency department. While the College supports this legislation, Congress first needs to address the larger Medicare physician payment problem of steep, annual reductions in reimbursement that will occur across all services for the next decade before directing scarce funds toward the 10 percent bonus payment. MedPAC hears testimony on physician workforce issues On April 13, MedPAC heard testimony regarding the “future workforce of physicians and clinical practitioners.” Following that, J. Wayne Meredith, MD, FACS, and staff met with MedPAC staff on April 30 to present information on trends in surgical workforce issues generally and on the growing problem of specialty emergency call coverage, in particular. Trauma care and reimbursementCongress passes trauma systems reauthorization bill On March 27, the House passed HR 727, the Trauma Care Systems Planning and Development Act of 2007, with the Senate following suit on March 29. The College strongly supported this legislation. President Bush signed the bill into law on May 3 and it is now Public Law 110-23. Introduced in January by Reps. Gene Green (D-TX) and Mike Burgess, MD (R-TX) and by Sens. Jack Reed (D-RI) and Pat Roberts (R-KS), this legislation reauthorizes the Health Resources and Services Administration's (HRSA) Trauma-EMS program through fiscal year (FY) 2012 with an authorization level of $12 million for FY 2008, $10 million for FY 2009, and $8 million for FYs 2010S2012. The law also creates a new competitive grant program for states that have already begun the process of establishing trauma care systems using national standards and protocols. Hospital and medical preparedness funding proposed Under provisions enacted under the Pandemic and All-Hazards Preparedness Act, (PubL 109-417) funds for hospital and medical disaster preparedness were moved in the president’s budget from HRSA to the office of the newly created HHS assistant secretary for preparedness and response. The act includes trauma systems as one of the overall national preparedness goals and also stipulates that at least one trauma center must be part of a consortium seeking preparedness grants to qualify for direct funding. These provisions were championed by the College and other trauma coalition members. The president’s FY 2008 budget provides $414 million for hospital preparedness grants and $15 million for Medical Reserve Corps. College supports trauma research funding The College sent a letter of support to Rep. John Murtha (D-PA), chair of the House Defense Appropriations Subcommittee, in support of the US Army Institute of Surgical Research to increase scientific knowledge related to trauma, burns, and all aspects of trauma research. The knowledge and information amassed through the National Trauma Institute, coupled with the new therapies that have been developed, will benefit military personnel and have powerful far-reaching benefits for trauma care in civilian settings.
Revised December 17, 2007
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