Letter to Georgia's Department of Community Health

staff contact: Jon Sutton, jsutton@facs.org

January 29, 2004

Richard Greene, Director
Division of Health Planning
Georgia Department of Community Health
2 Peachtree Street, NW
40th Floor
Atlanta, GA 30303

Dear Mr. Greene:

Over the past few years, the American College of Surgeons (ACS) has been concerned with an issue in Georgia relating to the Certificate of Need (CON) law and how the specialty of general surgery is defined. During the court case of Albany Surgical, P.C. vs Department of Community Health (DCH), the College submitted an amicus curiae brief challenging the department's definition of General Surgery as a multi-specialty for purposes of Georgia CON requirements. At this time, the College wishes to provide further comment on this issue as recent revisions to the rules issued by Georgia's DCH for CONs governing ambulatory surgical centers (ASCs) do not yet reflect the correct view of general surgery as a single specialty. This mis-conception will inappropriately and unfairly deny general surgeons eligibility for the benefits afforded by the single specialty exemption in the CON law.

It is universally recognized by academic and private healthcare institutions that general surgery is a distinct single medical specialty, just as unique and focused as any other single medical specialty. Although the term "general" is in the title of general surgery, it does not imply that surgeons in this specialty area: practice multi-specialties; are primary care physicians; perform every type of surgical procedure; or have no specialty status. Just the opposite is true.

Individuals entering careers and training programs in general surgery must have an MD/DO degree before moving on to specialize in this area. They apply to general surgery residency programs, and if accepted, undergo a minimum of five years of training in the specialty. This training is geared to educate the residents in the essential components of general surgery, including surgery of the head and neck, breast, skin and soft tissues, alimentary tract, abdomen, vascular system, and the endocrine system. It also includes the comprehensive management of trauma, burns, emergency surgery and surgical critical care.

Most general surgeons in this country have the above special training and expertise tested when they receive certification through the American Board of Surgery. This certification process parallels those of other medical specialties that also have defined areas of practice. In fact, hospitals consider general surgery as a single specialty for purposes of their physician recruitment, credentialing and granting of privileges for surgical procedures. Healthcare insurers also consider general surgery a single specialty practice as evidenced by reimbursement for specific types of procedures provided by the specialty.

Ambulatory surgery centers are facilities where high-quality surgical care is provided in a cost-effective and safe manner. As technology has improved, many surgical procedures, once limited to hospitals, have now been safely and appropriately moved into the ambulatory setting. Thus, the College believes that the department must carefully weigh their decisions in this area that would reduce patient access to specialized surgical care in these types of facilities. Therefore, we suggest the following revisions to guidelines governing CONs for ambulatory surgery centers:

1. Applicability 1 (Facilities Considered as Part of a Hospital) – This guideline expands the scope of which hospital ASCs do not need to obtain certificates of need to include ambulatory surgical services on premises outside the hospital's campus if the services are "integrated with other hospital services and systems, and the services are billed through the hospital's Medicare or Medicaid provider number and/or license number issued by the Department of Human Resources." While the College does not object to this guideline, we believe the regulations should also be expanded to exempt from CON requirements physician-owned ASCs offering general surgery services. In addition, providers wishing to expand or replace their facilities should be required to only include the costs associated with the new or upgraded surgical suites, not the cost of the entire project, when calculating the capital threshold under the CON requirements.
2. Definition 10 (Multi-Specialty Ambulatory Surgery Service) – Because general surgery is a single specialty, the words "general surgery or" should be stricken from this definition. To maintain this definition as currently written discriminates against the specialty and restricts patient access to high-quality, cost-effective surgical care.

Finally, the College takes issue with the process that surrounded development of these guidelines, particularly the composition of the Technical Advisory Committee (TAC). We are deeply troubled that membership on the TAC disproportionately favored the interests of the hospital community – effectively limiting the consideration of issues central to surgeons and their patients.

We urge the department to remove general surgery from the definition of a multi-specialty ambulatory surgery service. General surgery is clearly a single specialty, and physician-owned ambulatory surgical centers offering general surgery should be exempted from the CON process in the same way that other single specialty ambulatory surgical centers are exempt. Maintaining the status quo discriminates against those in the specialty who wish to provide high-quality ambulatory surgical care in their own ambulatory surgical center, and unnecessarily restricts patient access to quality surgical care.

Sincerely,

Thomas R. Russell, MD, FACS
Executive Director

TRR:jhs

cc:

Neal Childers, JD
DCH General Counsel

Office of the Governor:

John K. Watson
Chief of Staff

Trey Childress
Policy Director

Harold Melton, Esq.
Executive Council

The American College of Surgeons is a voluntary, educational and scientific organization devoted to the ethical and competent practice of surgery, and to enhancing the quality of care provided to surgical patients. For over 90 years, the College has disseminated medical and surgical information to the profession and to the general public, and it has been deeply involved in establishing standards of practice. With over 64,000 members, nearly half of which are general surgeons, the ACS is the largest surgical association in the world.

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