ACS Views on Legislative, Regulatory, and Other Issues

Workforce—

• Senate HELP Committee, 2/12/08, ACS Statement for the Record

Statement of

American College of Surgeons

to

Senate Committee on Health, Education, Labor and Pensions

RE: Addressing Healthcare Workforce Issues for the Future
February 12, 2008

The American College of Surgeons (ACS) commends the Senate Health, Education, Labor and Pensions Committee for holding this critically important hearing on the shortages in our nation’s health care workforce. We are grateful for this opportunity to present a statement describing surgical workforce issues.

While policy leaders often express concerns about the adequacy of the nation’s primary care workforce, ACS and others continue to warn that the problem is much more widespread. Indeed, there already are signs of an emerging national crisis in patient access to surgical care. In a commentary published in the November 2007 issue of the Journal of the American Medical Association (JAMA), Josef Fischer, MD, FACS, chair of the department of surgery at Beth Israel Deaconess Medical Center in Boston, MA, and chair of the ACS Board of Regents, warns that the “pipeline” that supplies the training of our nation’s general surgery workforce is broken, and that without immediate attention patient access to essential surgical care and the survival of small and rural hospitals is threatened.

The emerging crisis in the physician workforce must be faced by Congress. In the 1980s and 1990s, workforce analysts and public policymakers, with few exceptions, predicted that the U.S. would experience a substantial excess of physicians by the beginning of the 21st century. A number of peer-reviewed studies at both the national and state levels have reversed these predictions, and now most experts are calling for dramatic increases in the physician workforce.

The College is working with the Harvard School of Public Health on a study to determine the breadth of the surgical workforce crisis and its underlying factors. Focus groups of practicing surgeons held last October revealed that supply problems are being seen most frequently with regard to emergency department (ED) coverage. General surgeons warn that these shortages are most evident today in rural and/or low income areas. Furthermore, younger surgeons are subspecializing at an alarming rate, making them less qualified to provide the scope of care required in EDs, while older surgeons are nearing retirement age. Middle aged surgeons participating in our focus groups cautioned that their workday has expanded almost beyond their capacity and that they simply do not know who will be able fill their positions when they are gone.

In June 2006, the Institute of Medicine (IOM) released a set of reports detailing the deteriorating condition of the nation’s emergency health care system, titled the ”Future of Emergency Care in the United States”. These reports caution that our nation’s highly fractured system of EDs and trauma centers is plagued by overcrowding and ambulance diversion and remains ill-equipped to handle pediatric patients and major disasters. IOM concludes that the quality of the emergency care will continue to decline due in part to workforce shortages of the critical care specialists who are increasingly overburdened with uncompensated and complex patients that tend to inflate their medical liability exposure.

The IOM reports found that rural EDs, in particular, face persistent shortages of emergency and trauma on-call specialists, and they argue that alternative ways of enhancing emergency services in these areas must be identified. Concurrent with the release of the IOM reports the College released its own report titled “A Growing Crisis in Patient Access to Emergency Surgical Care,” which reached similar conclusions. In addition, many states have begun to respond with detailed analyses and action plans of their own.

MASSACHUSETTS:

The Massachusetts Medical Society (MMS) concluded in its previous five Physician Workforce studies (2003–2007) that “the physician labor market in Massachusetts continues to be under extreme stress and the forces that push the market into this unenviable state are numerous and are not likely to be easily reversed.” The study determines that shortages in the state’s physician workforce are emerging in many specialties, including surgery. In fact, the supplies of neurological and vascular surgeons in Massachusetts were classified as “critically low.”

According to the MMS 2007 study, the dominant factors leading to the deterioration in the state’s physician workforce are the rising costs of maintaining a practice, the ratio of housing prices to physician income, and increases in professional liability premiums. This analysis determined that roughly half of the physicians were altering or limiting their practice because they fear lawsuits and that many surgical specialties— including neurosurgery, orthopedics, and general surgery—had been significantly impacted.

Seventy percent of these MA physicians reported having difficulty filling physician vacancies and warned that the pool of incoming applicants is inadequate. The problem is even worse in community hospitals, with 72 percent reporting physician supply problems that necessitated altering the provision of services and 68 percent reporting they were forced to adjust professional staffing patterns. In the state’s teaching hospitals, the highest job vacancy rates for physicians were found in the surgical specialties, including vascular surgery, urology, and neurosurgery.

MICHIGAN:

In reaction to reports of physician shortages in Michigan, the Institute for Health Care Studies at Michigan State University convened a 2004 “Blue Ribbon Physician Workforce Committee” to analyze the physician the MI physician workforce issue. The Blue Ribbon Committee commissioned a study by the Center for Health Workforce Studies at Albany School of Public Health (CHWS) to determine the numbers of physicians needed in the state by 2020. This 2007 study found that the Michigan physician workforce shortage is 50 percent above the national average.

The need for surgeons in Michigan is especially acute. The CHWS study indicated the state will need approximately 700 new surgeons by the year 2020, including 500 general surgeons and 200 surgical specialists. The Blue Ribbon Committee developed a federal legislative action plan, calling on Congress to: (1) raise Medicare reimbursement caps for Michigan graduate medical education (GME) programs by 10 percent; (2) raise levels of Medicare payment for physician services; and (3) maintain Medicaid GME support to teaching hospitals.

IOWA:

Concerns about the physician population in Iowa led medical leaders, hospital executives, and medical education leaders to form the University of Iowa Health Care Task Force to analyze physician workforce trends in the state from 1996-2005. All types of physicians (including primary care and medical specialties) experienced positive rates of growth in Iowa—except for the state’s pool of surgeons, which remained stagnant.

According to the Task Force, the supply of general surgeons, neurosurgeons, and orthopaedic surgeons available to treat Iowans leveled off over this period, and the surgeon-to-population ratio was frequently below the national average. For example, only 65 percent of Iowans lived within 50 miles of a neurosurgeon.

The Iowa recruitment priorities listed by the study reflect a gap in adequate surgical care. In fact, of the top eight specialty recruitment priorities for Iowa half fall within the surgical specialties, including neurosurgery, orthopedics, and general surgery.

NEW YORK:

A 2006 CHWS analysis of physician supply and demand in New York noted that physician shortages are likely in the future, and that the demand for specialists is significantly stronger than that of primary care physicians. The study noted a significant decline (14 percent) in the number general surgeons in New York. Compounding the problem, general surgeons top the list of physicians who have indicated plans to reduce hours or retire.

Underlying Problems

The single most important factor shaping the surgical workforce issue today is declining reimbursement. Physician concerns center not only on reimbursement for the emergency services themselves, which frequently are uncompensated, but also on insurance payment for procedures that comprise a major component of elective practice. Analysis of CMS data demonstrates that reimbursement for surgical services has been declining quite steadily over the past two decades.

In addition, the Emergency Medical Treatment and Labor Act (EMTALA), originally passed to address the problem of patient-dumping by hospital emergency departments, is having a perverse impact on access to specialty care.  Physicians agree that EMTALA has an important purpose—to ensure that no one is denied emergency medical care because of lack of insurance or an inability to pay. But EMTALA has grown in scope and complexity over the following years and is generally viewed as an unfunded mandate to provide uncompensated care. This has had the unfortunate effect of driving surgical specialists away from taking call in our nation’s EDs. In a 2003 national survey of surgeons, conducted by the Robert Wood Johnson Foundation, 26 percent of respondents preferred not to treat trauma patients, and 50 percent would not take ED call at all if it were not required to obtain hospital privileges.

According to a 2004 report by the Kaiser Commission on Medicaid and the Uninsured, the cost of uncompensated care provided by physicians (estimated at $5 billion in 2001) is neither directly nor indirectly reimbursed by public dollars. As a result, financial pressures have caused the percentage of physicians who provide charity care to fall to 68 percent in 2004-2005 from 76 percent in 1996-1997, as explained by a 2006 report by the Center for Studying Health Systems Change.

A major concern for specialty surgeons who provide emergency care is the exposure to medical liability claims. Twenty-five percent of hospitals asserted in a 2004 Schumacher Group report that they have lost physician specialist coverage due to medical liability concerns. Over the years, the federal government has stepped in and established programs that do provide some limited medical liability protections, but these efforts tend to focus on primary care and office-based services. The Volunteer Protection Act, for example, applies only to individuals serving in not-for-profit organizations. In addition, Public Health Service Act section 224 provides Federal Tort Claims Act protection for services provided to patients of community health centers. Unfortunately, there are no liability protections for specialty physicians who provide EMTALA-related care in our nation’s EDs, where the risk is substantial. Furthermore, surgeons who provide care to patients referred by community health centers receive no protections under the statute. Clearly, the federal government can do more.

These problems are compounded by an aging surgical workforce that makes fewer surgeons available due to decreased workload capacity and retirements. Analysis of the American Medical Association’s Physician Characteristics and Distribution in the U.S., 2007 edition, shows that approximately one-third of the surgical specialties that are key to ensuring adequate emergency call coverage are age 55 or older (general surgeons 32 percent, neurosurgeons 34 percent, and orthopaedic surgeons 34 percent). Contributing to this shortage are provisions in many hospital by-laws that allow older physicians to opt out of ED on-call responsibilities. This upcoming retirement cliff in the surgical workforce makes the repair of this pipeline even more time-sensitive.  

Other professional trends add to the problem, including the growing movement toward specialization. Program directors report that over three quarters of all general surgery residents go on to pursue fellowships and sub-specialization. As their scope of service becomes narrower, a new and alarming trend has emerged—many surgeons no longer feel qualified to manage the broad range of problems they are likely to encounter in an ED and/or rural setting.

Potential Solutions

Extension of Federal Tort Claims Act

The College, along with other medical and physician organizations, supports the enactment of comprehensive, common sense medical liability reforms. While the College recognizes a federal solution may not be forthcoming for the entire physician community, limited protections should be introduced and passed by Congress. For example, Congress could provide liability protections for physicians that provide EMTALA-related care, or EMTALA-related uncompensated care by bringing these mandated services under the Federal Tort Claims Act (FTCA). The FTCA could also be expanded to include surgeons who provide services to patients who are referred through their primary care physician at a community health center.

Tax Deductibility of EMTALA Services

Arguments could be made for the deductibility of EMTALA-related care, on the basis that these services are provided under a federal mandate. (That is, they cannot be considered voluntary charity care.) Further, there are no federal “disproportionate share” payments and there rarely are state funds that physicians and surgeons can draw upon to offset the professional expenses associated with providing uncompensated care, as there are for hospitals. Tax credits or tax deductions could be provided for the practice expense and malpractice expense portions of Medicare’s physician payment amount, since those components are intended to reflect actual costs to the physician of providing the service; the physician’s time and work would remain “pro bono.”

A second option would be to adjust the overhead costs used in calculating Medicare practice expense payments to account for overhead associated with providing uncompensated care. Such an adjustment has already been made in calculating indirect overhead costs for emergency physicians who, in the aggregate, provide the most uncompensated care.

Regionalized System of Emergency Care

In many areas of the country, emergency medical services are highly fragmented, poorly equipped, and insufficiently prepared for day-to-day operations, let alone major disasters. Furthermore, EDs are increasingly overburdened. The 2006 IOM reports provide a comprehensive overview of the many factors that are stressing our nation’s emergency departments and threaten access for those patients who need prompt and expert care. Among many recommendations, the IOM suggests a concept of expanding regionalized systems to improve access to highly specialized care, modeled after the trauma system design that is so familiar to surgeons. Regionalized, accountable emergency care systems show substantial promise in addressing the complexity of an efficient EMS response, which must properly manage the coordination of a number of groups, agencies, and individuals involved—from incident recognition to providing specialized care to public education.

National Health Service Corps Expansion

The National Health Service Corps (NHSC) program was originally enacted by the Emergency Health Personnel Act of 1970 to respond to the geographic maldistribution of primary care health professionals. The corps plays a critical role in providing care for underserved populations in both urban and rural settings by the establishment of scholarship and loan repayment programs that provide education assistance to health professions students and loan repayment for fully trained health care professionals in return for a period of service in a health professional shortage area (HPSA).

Unfortunately, the NHSC is only available to the following health care professionals: allopathic or osteopathic primary care physicians, primary care certified nurse practitioners, primary care physician assistants, certified nurse-midwives, general practice dentists, registered clinical dental hygienists, health service psychologists, clinical social workers, licensed professional counselors, marriage and family therapists, and psychiatric nurse specialists. To improve access to specialty physicians in rural areas, where the surgical workforce problem is most acute, the National Health Service Program should be expanded to include general surgeons.

Graduate Medical Education

The College supports proposals to help relieve the enormous debt being incurred by surgical residents, including efforts to remove the limits on tax deductions for student loan interest, allow young surgeons who qualify for the Economic Hardship Deferment to utilize this option beyond the current limit of three years into residency, and increase the aggregate combined Stafford loan limit for health professions students.

Conclusion

We would like to reiterate on behalf of the over 77,000 Fellows of the American College of Surgeons our firm belief that there is an emerging crisis in patient access to surgical care. Repairing the surgical workforce “pipeline” will require considerable political will. Many of the solutions the ACS has identified are large in scope and envelop the structure of our health care system and the interests of many stakeholders. Certainly, it is time for policy researchers and policymakers to begin addressing these difficult issues, bearing in mind that no stakeholder has more to lose than the surgical patient. Thank you again for allowing us to submit this statement for the record and thank you for bringing to the attention of the Committee an issue that is vital to the surgical care of the patients we serve.

ACS Views on Legislative, Regulatory, and Other Issues

Advocacy and Health Policy