Surgery News - February 2008 - (Page 8)

OPINION FROM THE COLLEGE SURGERY NEWS • F E B R U A RY 2 0 0 8 ACS Initiatives Aim to Meet Surgeons’ Expectations T schedule and have suggested viable alternatives. One piece of legislation closely aligned with our recommendations that Congress considered last year was the Children’s Health and Medicare Protection (CHAMP) Advocacy and Health Policy Act of 2007. In addition to reUnderstandably, many ACS newing and expanding the Fellows are frustrated with State Children’s Health Insurthe federal government’s failance Program, CHAMP called ure to implement long-term for replacing the 10.1% and 5% solutions to ongoing Medicare reimbursement cuts Medicare reimbursement slated for 2008 and 2009, reproblems. Organized medispectively, with 0.5% increases. cine has pushed for reform. BY THOMAS R. It also would have supplanted For instance, the College and RUSSELL, M.D., FACS the SGR with a new system of its allied specialty societies have highlighted the problems associat- six expenditure targets and conversion faced with using the sustainable growth tors for various categories of physician serrate (SGR) to formulate the conversion vices. This approach holds promise for factor in the Medicare physician fee ending the current across-the-board payhis past year certainly presented the American College of Surgeons with challenges on many fronts, and we responded with several robust initiatives on behalf of our members. ment reductions, regardless of each service category’s growth in volume and spending. Unfortunately, Congress passed only a stopgap measure that provides modest increases in Medicare physician payments for the first 6 months of 2008. Instead of reducing the Medicare fee schedule conversion factor by 10.1%, legislation President Bush signed on Dec. 29, 2007 instructs the Centers for Medicare and Medicaid Services (CMS) to increase by 0.5% payments for all services provided between Jan. 1 and June 30, 2008. Beginning July 1, 2008, however, the 10.1% reductions from 2007 payment levels will take effect unless Congress intervenes again. Although this measure offers some temporary relief for surgeons, the College and its allies find the prospect of revisiting this issue yet again rather discourag- ing, especially since thousands of Fellows contacted their senators and representatives in the closing days of last year’s legislative session to urge passage of a more comprehensive bill. Because of the change in 2008 payment rates, CMS extended the period for physicians to sign Medicare participation agreements through Feb. 15. When deciding whether to participate, surgeons should consider the uncertainty of Medicare payment rates after July 1, 2008, especially since CMS has not indicated whether physicians will be allowed to revisit participation if the midyear reductions occur. Over March 9-11, 2008, we will host the first Joint Surgical Advocacy Conference with several surgical specialty societies. We expect this event to attract hundreds of participants and give surgery the presContinued on following page POINT/COUNTERPOINT Do We Really Need More Doctors? Training more doctors fails to address the core issues. he on physician shortages (Surgery News, Tout ofarticle withSeptember 2007, p. 3) is touch reality. First, let’s assume that we truly need to increase the number of matriculating students in U.S. medical schools by as much as 50%. Who will teach those young doctors? In the first 2 years of school, teachers are paid to teach, and—with the exception of anatomy labs—classrooms can easily handle more students. Similarly, in the third year of medical school, the introductions to clinical medicine courses are often taught by salaried people. The problem lies in the last year, when clinical rotations take place, and in residency positions. Teachers for these years are overwhelmingly voluntary. Yet how can already overworked people be expected to extend their workdays at the expense of family and other personal time? Medicine is the only profession in which most of the core mentoring is unpaid, and for which the teaching responsibility extends the working hours of the “master.” If we are to ramp up the number of clinical residency slots, teachers must be compensated, or no one will do the job. Consider the pressures against increasing the number of physicians, and the reasons why money will not easily be forthcoming for this task. So far, even in areas where there is a doctor shortage, the public does receive care. There is no huge outcry that people are being abandoned by American medicine. My region desperately needs vascular surgeons, yet no one has been turned away, and we have been working harder than ever to avoid cancellation of elective surgery for urgencies. However, we cannot keep this effort up forever. Who benefits from this contraction of access? All payers do. Witness the outcries each year when insurance premiums increase—yet that money never seems to increase the net fee schedule for any surgeon. The problem is that the volume of service is steadily increasing faster than the population is growing. All measures to control volume have failed for 3 decades now. Overt rationing of care has proved totally unacceptable to the American public. What can and will work is to contract the provider base, creating “back door rationing” quickly. Health economists know that the entry of the “n + 1” specialist to a region does not improve health care in general, but it does increase the number of services billed. Reducing the number of physicians, notably specialists, is the only way to cut the growth of services and expenses. My prediction is that political expediency will hold forth to prevent new medical school construction and to avoid a huge increase in the number of physicians—so long as the public’s access to care is not seriously affected. The rub is that when a shortage does occur, it will be far too late to fix it, given that it takes a decade for the average surgeon to progress from matriculation in medical school to entry into practice. The College seems to fail to understand these realities. Meanwhile, many of us in unpopular geographic areas are working far too hard, and we will retire earlier than we would if our workloads were lighter. The loser in this scenario is the American public. If a surgeon has a functional career expectancy of about 33 years, losing 3-5 years due to early retirement translates into a lifetime loss of productivity of 10%-15%. We cannot train enough surgeons to replace such a loss. Someone needs to look at the problem of surgeon retention in practice, just as matriculation and teaching deserve attention. All three together are headed in the wrong direction. ■ JEFFREY L. KAUFMAN, M.D., FACS, is a vascular surgeon at Baystate Vascular Surgery in Springfield, Mass. We must press hard to expand training programs. Dr. Kaufman refers was based on Forum on The articleathe AnnualWorkforcetoIssues presented at Meeting of the American Surgical Association in May 2007. Organized by ASA President Jay Grosfeld, FACS, the Forum included three essayists: Dr. Richard A. Cooper, professor at the Leonard Davis Institute of Health Care Economics of the University of Pennsylvania, Philadelphia; Dr. Darrell G. Kirch, president and CEO of the Association of American Medical Colleges; and myself. (Proceedings from the symposium can be read in Annals of Surgery, Vol. 246, Oct. 2007.) Dr. Kaufman raises many valid points. For 30 years, workforce studies predicted a physician surplus of 145,000 by the year 2000, but recently, a total reversal of these estimates has occurred. Most experts now predict a shortage of physicians as severe as 200,000 by the year 2020. The American College of Surgeons (ACS), the American Surgical Association, the American Medical Association, and the Association of American Medical Colleges have all affirmed the shortage and recommended an increase in medical school and residency capacity. In fact, 16 new medical schools are in the process of being established or are under consideration. It also has been recommended that the 1996 cap on Medicare funding for graduate medical education be lifted, and the number of residency positions increased. Dr. Kaufman notes that when a shortage does occur, it will be too late to correct the problem because it takes a long time to train surgeons. Most experts believe, however, that a shortage has already occurred and that it will worsen before it gets better. The American College of Physicians has declared a crisis in the shortage of primary care providers. In addition, a study done by the ACS and the Institute of Medicine shows extensive deficiencies in the number of surgeons in all specialties who are available to take emergency department call. The hospitalist movement and the increasing delay in obtaining hospital appointments signify an evolving shortage. An effective response to the shortage is overdue, and it will take 25 years to catch up. Dr. Kaufman correctly observes that we may lack sufficient clinical teachers as the number of trainees expands. Clinical faculty have been the largest faculty group to expand in the past 20 years, but an increase in students and the 80-hour work week for residents will likely produce a shortage in instructors. It is also accurate that one-third of physicians are older than 55 years of age, that the environment in which medicine is practiced today is believed to be less satisfactory than in the past, and that many surgeons anticipate retiring early. I differ, however, with Dr. Kaufman in several areas. There is strong evidence of a shortage of physicians of all types. We must press hard to expand our facilities and our residency training programs. We should also address retention and the practice environment. With the concurrent changes in social and scientific advances and changes in medicine, physicians need to be actively engaged in efforts to correct this problem for the sake of society and

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Surgery News - February 2008 Contents IOM Committee Looks Into Safety Of Work Schedules Expertise Can Extend Liver Resectability Report Faults Specialty Hospitals' EDs Meeting Expectations Silver Lining HOD on Health Longer Liver Life?

Surgery News - February 2008

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