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Ann Thorac Surg 1998;65:905-908
© 1998 The Society of Thoracic Surgeons
a Division of Cardiothoracic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
Address reprint requests to Dr Gardner, Division of Cardiothoracic Surgery, Hospital of the University of Pennsylvania, 6 Silverstein, 3400 Spruce St, Philadelphia, PA 19104
Presented at the Thirty-first Postgraduate Program of The Society of Thoracic Surgeons, New Orleans, LA, Jan 25, 1998.
Through the activities that I have been involved in for The Society of Thoracic Surgeons (STS) over the past several years, I have had the opportunity to see close up many of the changes to our health care system that have occurred in the political arena, as well as the reactions in the broad physician community to these changes through my American Medical Association work. I am going to review where we are today with respect to United States government policies for health financing, with a particular focus on how we have gotten to where we are on the physician reimbursement side of things. I will then describe briefly what is being done by the STS to deal with the major reductions in support for specialized surgical care for Medicare recipients as a result of the present proposal for drastic changes in the pattern of physician reimbursement. I will conclude by suggesting not just actions that we should undertake in the face of the current reimbursement crisis but attitudes that we need to adopt to ensure the continued growth and progress of our speciality on all fronts, including patient care, education and training of residents, and biomedical research.
First of all, where are we at the present time and how did we get here? In the Medicare program in the US, reimbursement for some physician services, especially for surgical treatment, has decreased by as much as 50% over the last 10 years. If the Medicare practice cost reform measures that were announced last year are implemented as proposed, additional reductions of 20% to 40% in surgeons’ reimbursements are expected.
Many of you have seen the excellent summary of recent developments in the Medicare program by Bob Wilbur that appeared in The Annals of Thoracic Surgery in June 1997. This is a must-read article and is titled " ‘Resource-Based’ Practice Expense: How We Got Where We Are Today." Bob is director of Government Relations and heads the STS’s Washington office. He and his assistant, Corrine Colgan, along with Mike Thompson, the Executive Director of The Society, and Don Turney, the Associate Executive Director, both in the Chicago office, are the key individuals in the efforts to manage the business affairs of The Society, including the organization of the annual meeting and especially our government relations activities and our important interactions with other medical associations, including the American Medical Association. In the June 1997 article, Bob summarizes the evolution of the Health Care Financing Administration (HCFA) policy and reform measures in the Medicare Program, with particular reference to the current practice expense revisions proposed last January.
Briefly, the Medicare program was established in mid-1960’s under the shepherding of the Johnson administration and with the strong support of a Democratic Congress. The establishment of a national health system had been discussed in the US for some time before, and the newly established Medicare program, for better or for worse, was seen by many people in government and by the vast majority of Americans as an appropriate Federal Government program to insure the health and well-being of older citizens. National health systems were already established in most other developed countries, and despite a deep-seated resistance to the concept of a mandatory national health system in the US, the new Medicare program, which would insure excellent medical care to all older Americans regardless of economic status, won wide public support.
Several important facts surrounding the implementation of the Medicare program need to be kept in mind. First, many medical groups, especially the American Medical Association, opposed the establishment of the Medicare program, claiming that this was just the first step in a philosophically un-American nationalization of something personal and private. Despite what were genuine philosophical concerns about putting government administrators and politicians into positions of responsibility for health care delivery, the opposition to Medicare was viewed by many as narrow, self-interested, and driven by financial concerns of doctors.
Notable demographic factors that existed at the time the Medicare program was established were a shorter life expectancy for Americans than is the case today, a smaller percentage of elderly people in the population, and fewer of the extraordinary capabilities in health care that we take for granted today. Coronary bypass grafting was yet to be undertaken successfully when the Medicare program began. Intensive care and coronary care units were not established as a routine, nor were current patient monitoring capabilities, advanced radiographic imaging and diagnostic capabilities, or pharmacologic advances including such commonly used drugs as ß-blockers and calcium-channel blockers.
Within the first few years of its existence, it was clear to all who looked closely at the federal budget that the Medicare program was exploding in scope and cost. The elderly portion of the population was growing geometrically, our ability to treat all sorts of previously fatal illnesses was expanding dramatically, and the cost of medical care was rising at an even higher rate than the longevity of our population. Public policy experts and economists, but not necessarily politicians at that time, realized what was happening in health care in America and concluded as early as the late 1970s that health care expenditures by the government would have to be curtailed. One obvious way of controlling the health care budget is to limit the spectacular but costly developments that have occurred in advanced medical care.
Enter the politicians at this junction, those whose responsibility it is to make government programs work. These are also people who are empowered to make the necessary public policy decisions, but they are empowered only by winning the support of the numeric majority of voting US citizens.
Cardiothoracic surgeons during this golden period for our specialty were being rewarded for our extraordinary education and training, hard work and demanding lifestyle, and the astounding developments in our field by becoming some of the wealthiest members of our society. Appropriately we had become one of the most successful and highly rewarded groups in Medicine.
Within the broad medical community at this same time, there were many who espoused arguments such as these, that the most effective way to control the growth of health care expenditures is to improve primary and preventive care and thereby reduce the need for costly care in the final stages of an individual’s illness. Another hypothesis proposed was that physicians who deal with diagnostic medical dilemmas are more cognitive, that is, use more intellectual energy, than those who perform surgical procedures, and therefore should be rewarded at a higher level than surgeons. There were even those who suggested that an obvious and necessary solution to the impending health care financing crisis was to deny very expensive care to patients with poor prognoses or to those approaching the end of life. The statistic that the bulk of Medicare dollars are expended in the last months of life was a commonly heard mantra during the recent Clinton health care reform efforts early in his first presidential term.
Furthermore, and at the same time as those of us in cardiothoracic surgery, pediatric heart surgery, and other specialties such as surgical oncology, neurosurgery, and so on were laboring away in our highly demanding and intensive specialities, many of our medical colleagues were at work in the public sector successfully convincing public policy experts and political leaders that there are major distortions in the payment policies of the Medicare program. Congress, with its research groups such as the Physician Payment Review Commission and the General Accounting Office, and the Executive Branch through HCFA bought into the notion that physician reimbursement could be normalized across medical specialties using comparative work indices. This concept was described as relative work values, in which the mental and physical effort, the required knowledge base as well as the stress or intensity associated with any given medical service or procedure, could be compared across a broad matrix of medical services to ensure a fair and equitable reimbursement formula.
This was the origin of the resource-based relative value scale, which was developed first as an academic exercise at the Harvard School of Public Health by William Hsaio and his associates and then became the basis for the implementation in 1992 of the resource-based relative value scale for the Medicare fee schedule as we know it today.
Even before the 1992 Medicare fee schedule reforms, Medicare reimbursement for some specialties such as cardiac surgery and ophthalmology were reduced on the basis of being overvalued. Then in 1992, when the revised work values were put into place in the Medicare fee schedule, there were additional major reductions in the reimbursement patterns for advanced medical care, especially procedural care. It was well known to the bureaucrats and to the primary care physician community back in 1992, but not well recognized by many others, that the second shoe of Medicare physician payment reform would fall a few years down the line when the expense, or overhead, component of the Medicare fee schedule would be put on a similar relative-value basis. This second step in the Medicare fee schedule reform has been the practice expense fiasco that HCFA introduced this time last year and that is projected to decrease reimbursement for cardiothoracic and other surgical services by another 25% to 40%. And it is this most recent thrust by HCFA to further devalue surgical services in relation to office-based physician services that has finally brought our specialty to a state of full attention. Unfortunately, much of the damage to our economic status had already occurred during the first or work phase of the Medicare reform, complicating our current efforts to change the Medicare physician payment formulas.
Reactions by our thoracic surgery leadership and by many practicing thoracic surgeons to HCFA’s latest round of physician payment redistributions have been strong and vigorous. It is sobering, however, to realize that despite the scope of this change in physician reimbursement policies by the federal government and the likely extent of the economic impact on our specialty, many thoracic surgeons continue to ignore this challenge to the future activities of our specialty by failing to become active participants in and supportive of the actions that have been undertaken by the thoracic surgery societies to address the crisis.
The STS has been dealing with the Medicare reimbursement crisis on many levels. On the front line, our Washington staff have been engaged directly with HCFA, and we have provided the Agency with well-informed thoracic surgeons who have participated in HCFA’s review and refinement panels on physician work, practice expenses, and practice management issues. In addition, led by our professional staff and consultants in Washington, thoracic surgeons have had a series of visits and engagements with congressional representatives on Capitol Hill and in the legislators’ home offices, in an effort to win support from members of Congress for relief from the devaluation of advanced medical care that is resulting from HCFA’s changes to the Medicare fee schedule. We have expressed concern about the damage that will be caused to what has been the most successful health care system in the world as a result of such major cuts in support for specialty medical care. We have had to deal, however, with the perception that is fostered by other groups in medicine that our interest in this issue is based entirely on the damage that Medicare reform is doing to our earning capacity.
The STS, in conjunction with The American Association for Thoracic Surgery and a number of regional and state thoracic surgery societies, has begun a process of member education, political action, coalition building, public education, and the like, to help us turn a seemingly narrow and parochial argument about payment for surgical services into the more important and relevant concerns about access to specialty care and continued support for advances in medical treatment.
Our national thoracic groups and especially the Thoracic Surgery Foundation for Research and Education have actively encouraged and supported the participation of thoracic surgeons in endeavors such as the Harvard-Kennedy School of Government academic courses on health care economics and health care reform. An impressive number of our fellow thoracic surgeons from the full spectrum of our specialty in terms of subspecialty interest, practice orientations, geographic origins, and age have participated in these educational programs at Harvard. Other thoracic surgeons have found the time to broaden their academic and political experiences by pursuing additional education in similar courses elsewhere. Another feature of the STS’s efforts to deal with the current Medicare reimbursement crisis has been to establish a Health Policy Study Group under John Mayer’s and Jack Matloff’s direction, with the expectation of developing proactive positions that will allow us to anticipate health and public policy opportunities that will support the continued development of our specialty and of new medical advances. Other important study groups established this past year are the Public Affairs Committee headed by Vic Trastek and the Industry Coalition Committee led by Hal Urschel. As many of you already know, the STS Internet Web Site is a rich source of information about the evolving health care landscape.
What are we to do now? Are we in the damage control mode only? Have we missed the boat politically? Are we headed for such inappropriate redistributions of support for physicians that cardiothoracic surgery and other advanced medical specialty areas will be attractive only to those who are willing to sacrifice themselves on the altar of hard work for altruistic reasons? How are we going to encourage medical students and surgical residents that this specialty, which has been so phenomenal in its accomplishments in the past 25, 30, or 40 years, is still going to be worth the 8 or 10 years of training after medical school and will still warrant the personal sacrifices required of us to do an outstanding job caring for increasingly more challenging patients? Although none of these are easy questions to deal with, these are real concerns that are now affecting our specialty.
Among the things that we must do to deal successfully with this challenge is to make sure that we define the nature of the crisis in its proper terms. It cannot be portrayed simply as a threat to the level of reimbursement for doctors, especially not for surgeons. The real crisis is that we have a health care program in this country that is going through the ceiling in terms of cost. With the aging of our society, the Medicare system is unable to sustain itself long-term without restricting access to care or more preferably altering its methods of financing. The current Medicare system is cost driven, and the government has established it in such a way that every recipient is meant to have equal access. But if access is denied or rationed, because of inadequate government support, no one’s needs will be meet. Furthermore, neither the patient nor the doctor, under the current Medicare rules, is able to seek or provide care outside of the government-determined price limits. Now, we hear that President Clinton would like to extend price-controlled Medicare beneficiary status to even younger patients who choose to retire early or who lose their commercial insurance.
The Medicare program is an extraordinary anomaly in this "live free or die" society that we consider ourselves having in the US. The safety net that we thought we were establishing for our elderly citizens may become a weblike ceiling that will stifle developments in medical science and health care advances for the future. The real threat to our specialty now is not how much or how little we are getting paid but whether or not we are going to be able to continue to do the things we have developed so brilliantly over the years, which have resulted in improved survival and improved quality of life and function for so many patients.
Look at the fiasco we are dealing with now with lung volume reduction surgery for emphysema, truly one of the most miserable of the terminal chronic illnesses afflicting people. Talented chest surgeons have developed techniques that improve the quality of life for many patients with severely symptomatic chronic obstructive pulmonary disease. The Medicare program administrators, realizing that thousands of patients could be candidates for such an operation, and dealing already with a fixed level of support from the federal government for health care services, are forcing us through what many of you know are unreasonable hoops to demonstrate that this new surgical treatment is, in fact, effective and not experimental and therefore, parenthetically, reimbursable.
We must, as a small, select, and proud specialty, be able to appropriately influence public policy and health care policy in the future to ensure that access to appropriate cardiothoracic surgical care is guaranteed for our fellow citizens. We need to develop the contacts and relationships within organized medicine, within our communities, within the academic community, among economists and health care planners, and especially with politicians that will result in an understanding and appreciation for what is at stake here. To succeed at this, we as practicing thoracic surgeons must devote some of our time and effort to things that we have in the past considered peripheral or "not so important": things like hospital and medical society committees, local and state political activities, public education efforts and media outreach, and so on.
We also need to be smart, tough, and united. We need to work the political scene as hard as it takes to get the attention of politicians, legislators, public policy experts, and media leaders through a multipronged approach. We also should explore the appropriate boundaries for organizing ourselves politically and through coalitions to make clear to all segments of our society that there are limits to what we are willing or able to do without appropriate support. And very importantly, we need to move forward and away from the current, competitive orientations that often exist toward other members of our own specialty, whom we view as competitors for patients and health care dollars, to positions of mutual respect and support and professional cooperation. There are many local, regional, and national groups and organizations that we can participate in, and the STS is an ideal vehicle for all thoracic surgeons at this time.
In any challenging or crisis situation like the one we are facing now for our specialty, one can and must find opportunities for progress and growth. Our specialty needs to define itself and its value to our society in ever clearer and more resonating terms. We, as individual thoracic surgeons, need to recognize that we will not be successful to the same extent that we have been in the past if we do not involve ourselves in the public arena and become much more engaged in the political process. We have been leaders and innovators in medicine in the past, but we must extend that leadership role to become spokespersons and leaders in our communities, both lay and medical. We have been one of the most accomplished groups of physicians and surgeons ever to labor in this great profession of medicine. Do we want to let a health care financing crisis knock us off our well earned place high up in the hierarchy of medical care? ... No. We want to say to those young people who are coming into this specialty behind us that this is a marvelous way of life, that we are doing great good for our fellow citizens. We must learn how to become more articulate spokespersons for our mission, and we must pay more attention to our specialty’s need in the public policy arena, in addition to our continued dedication to the advancement of medical science and education.
Bear in mind that every historical crisis has also represented an opportunity for progress beyond the imaginings of those who first confront the crisis. I am certain that with all of the extraordinary heritage and talent that exists in our specialty, we will be able to advance our mission despite our current unfavorable political situation. Remember, as thoracic surgeons we are and have been leaders in medicine.
Finally, don’t fall into the trap of only asking what the STS is doing about this reimbursement crisis. We are the thoracic surgeons, and many of you here are the future of the specialty. Let’s all of us ask ourselves what we can do to advance our specialty, not the other way around.
This article has been cited by other articles:
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  T. J. Gardner Influencing the political process for cardiothoracic surgeons J. Thorac. Cardiovasc. Surg., April 1, 2001; 121(4): S32 - 34. [Abstract] [Full Text] [PDF]
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 T. J. Gardner The medicare program and thoracic surgery: challenges for the new century Ann. Thorac. Surg., May 1, 2000; 69(5): 1312 - 1314. [Full Text] [PDF]
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