Socioeconomic activism in a changing medical workplace

The beginning of socioeconomic engagement 

I would imagine that if one goes back to the evolution of the socioeconomic activities of American Surgery, particularly general surgery, one must go back to the early 1980s when Medicare began to engage with Dr. Tsiao of the Harvard School of Public Health. Prior to that general surgery had been absent and had been extremely quiescent as far as any involvement in socioeconomic areas. General surgeons, I suppose, were still the last “compleat physicians,” taking total care of their patients. So long as they were allowed to operate on and care for their patients and the workload was not too much of a hassle I think most general surgeons would be happy operating on and taking care of patients. Indeed, with regard to Blue Cross and Blue Shield and fee setting, general surgeons were notable by their absence. Whereas, the orthopedic specialties placed an orthopedic surgeon on every board that was determining fees which helps explain some of the differences in fees that exist to this day, general surgeons were conspicuous by their absence.

In engaging Dr. Tsiao and the Harvard School of Public Health, the Health Care Financing Administration (HCFA) knew that the methodology was never intended to be used for reimbursement. However, it was available and the HCFA decided to take advantage of it. I got involved in this area about the mid to late 1980s at which time surveys were being done as to the amounts of time that were being carried out for certain procedures, obviously to be used as a component of reimbursement. Here again, the general surgical community completely misunderstood the purpose of the surveys. Testosterone ruled rather than common sense. People who could not even get through the abdominal wall in 30 minutes began to put down times of 90 minutes for a low anterior resection. Indeed, individuals thought they were advertising their own skills and minimizing times rather than putting down accurate times. I personally remember a situation in which a group of us were sitting at the Washington office of the American College of Surgeons, reviewing these surveys as to their veracity and one of the members of the committee said openly that he never took more than 40 minutes for an inguinal hernia. I asked his permission to call his operating room and ask the operating room if they had data concerning this gentlemen’s last 50 hernias and what the median time was. They responded that it was 64 minutes. That was what I told him and he was shocked. That was a good example of how we deliberately, it seems, underfunded our reimbursement.

Regardless of what the methodology was, as it was reconstructed subsequently, and as we in the College later engaged some of the consultants that were used by Tsiao and HCFA at that time, it was clear that the methodology was intended to penalize surgeons. To put it kindly it may have been disingenuous, but perhaps bordered on the fraudulent. In any event the damage was largely done and general surgery has been playing catch-up ever since.

General surgery could not even generate the interest to help write the C.P.T. codes initially. It is alleged that the C.P.T. codes were largely written by a plastic surgeon. In contrast, the other surgical specialties concentrated on the C.P.T. codes and getting adequate C.P.T. codes for the declinations of various procedures as well as obtaining adequate reimbursement. This was true of most of the specialty academies with which the socioeconomic area remained a very prominent part of their activities.

The American College of Surgeons belatedly began to engage in these activities. However, the College representing general surgery had heretofore been almost entirely an educational and scientific organization and it required a major change in direction for such alterations to take place. This was carried out at the important regents’ retreat of 1985 at which it was decided to establish a socioeconomic department and to begin to engage in socioeconomic representation of the Fellowship. My own initiation into this area of the College began shortly thereafter at the behest of George Block and Alec Walt from the College. Ward Griffen, at that time the Executive Director of the American Board of Surgery, with Alec Walt and George Block constituted a triumvirate that supported the survival of general surgery.

When I joined the College’s effort, Isidore Cohn had taken on the responsibility of C.P.T.’s and George Block recruited John Gage, Frank Opelka, Skip Collicott, myself, and others to begin with, to carry the load in what later became the Coding and Reimbursement Committee of the College. Much of the damage had already been done and it was our task to try to undo what had happened to general surgery. For a time we were successful. We brought forth many new codes, did surveys and with Gage and Skip Collicott at the Relative Value Update Committee were successful to a certain extent in updating the fee schedule. Most of us knew that while we were participating that this was going to be not just for Medicare, but that ultimately all payment was going to be based on Medicare principles and reimbursement. Therefore, we were basically dealing with reimbursement for the entire general surgery. Initially, we made a great deal of progress. Bart McCann was the Medical Director of HCFA and determined what we were doing and thereby initiated the concept of budget neutrality by family; that is if we put forth a new code for something that we felt was more complicated this was going to have to come out of the overall payment per family and the value of the more common every day procedures would fall. This acted as a damper on our efforts to try to upgrade payment. Ultimately, the concept of overall budget neutrality was probably the only area in the United States in which the absolute and relative payment throughout a decade, which, although a period of relatively low inflation, nonetheless had increasing prices for services and the cost of labor.

Problems multiply 

Most of us who entered the process entered it in the effort to try to help, however, we rapidly became disillusioned by the cynicism and sometimes the underhandedness that accompanied the entire area of reimbursement and HCFA. How many of you remember the issue of “overpriced procedures” such as gallbladders and hernias? This was simply a one time, or perhaps more than one time since it was permanent, decrease in fees for gallbladders and hernias simply because HCFA thought they were paying too much for them. What does overpriced procedures mean? Who said so? Surgeons took this in stride and there was no revolt as there probably should have been. However, for those of us who were working in the area the cynicism and the desire to pay physicians less, which seemed to be all we could see with HCFA, began to take its toll. Those of us who were well intentioned, perhaps slightly idealistic, quickly became disabused of this. Indeed as one high official of HCFA personally told me “I don’t know why you guys continue to work with us and trust us. We lie. We cheat. We steal. We tell you one thing and we do another. I am surprised you still work with us at all.”

In the early 1990s culminating in 1994 the hypothesis was finally sold to HCFA that primary care was the answer to the nation’s health ills, that prevention, wellness and the avoidance of late procedures were the way to go. Congress basically stated its intention to redistribute income from proceduralists to primary care. Thus HCFA was able to set the houses of medicine against each other. The issue of practice expenses then emerged. Paul Ebert proposed that we should forget about practice expenses and keep the two conversion factors but failed to get a hearing. I represented the American College of Surgeons in one of the principal practice expense committees and it was clear when I walked into the room that it had already been decided. The working hypothesis was that surgeons didn’t need an office when they were in the operating room. Also, that their nurses who helped them and made rounds with them were not to be included as part of direct expense. The entire exercise was a sham. Further insults followed. The Emergency Medicare Treatment and Labor Act (EMTALA), originally conceived as an unfunded mandate, was abused as hospitals undertook mergers, especially in rural areas. Hospitals that were separated by 50 miles could then, for example, put two neurosurgeons, the only neurosurgical group in the rural area, on call on both hospitals.

This evolved thus to the current status of medicine. We find a medical system previously quite good, perhaps not perfect, especially with the care of the indigent, which is totally dispirited, a sullen, demoralized work force, which is having difficulty in attracting its successors with resources of physicians offices being stretched to the breaking point. In various surveys of various physicians and especially surgeons four issues constantly are seen, including in no particular order:

With respect to Medicare I had long predicted a crisis of access in which, as payments became more and more inadequate (witness the 5.2% cut in reimbursement this year) that Medicare patients were going to begin to have difficulty in getting appointments. Twenty-four percent of physicians now admit and probably there are many more that do not admit it, that they keep Medicare patients waiting to get appointments or refuse to see any new Medicare patients or for that matter any new patients above the age of 60. Crises of access are going to extend to all insured patients. Physicians are leaving practices and setting up “boutique practices” in which they require a retainer of anywhere between $1,500 and $20,000 per family. In exchange they will limit their practice and take enough time with patients to treat them as they should be treated. The decreased number of applicants to medical schools, the residents leaving medicine after completing their residencies (especially at good institutions) the unfilled places in general surgery, the “pushback” with hospitals banding together and physicians banding together and refusing to take contracts all witness a crisis that is upon us.

By next year with further cutbacks in Medicare I predict that 50% of physicians will be refusing to take Medicare patients—at which point the four-letter word that terrifies all Congressmen, the AARP, will come into play and Congressmen’s phones will be ringing off the hook.

Medicare patients are not the only ones experiencing a crisis in access. Costs are skyrocketing. Managed care organizations did not manage care—all they did was manage the cost. The Ponzi scheme of using additional enrollments to hold down the premiums is now over and premiums are going up at 15% to 20% annually as their inefficiencies get even more striking. We have been told that it will take approximately 130 billion dollars to fix Medicare over the next 10 years and it will not fix it entirely. The fix that Medicare envisions is probably not enough for most physicians and it is unlikely that most physicians will, even at that point, take Medicare patients.

George Sheldon has played a major role trying to fight this. He has been at the center of the activities of the American College of Surgeons, various other national organizations, and serving as President of the AAMC. He has pushed repeatedly, in addition to the scientific and educational side of the College for there to be a socioeconomic side to what the House of Medicine does. He was a member of a select committee of five which helped organize the Health Policy Steering Committee, which one of its accomplishments was to change the structure of the College for the first time since 1913 so that a 501 (c) (6) could expand some of the socioeconomic activities of the College and found a Political Action Committee. The College has determined that it needs some help with its activities and that lobbying was perfectly appropriate for its fellows.

Where do we go from here?