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Ann Thorac Surg 2000;69:1312-1314
© 2000 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, 4 Silverstein, 3400 Spruce St, Philadelphia, PA 19104
e-mail: gardnert{at}mail.med.upenn.edu
The 1990s was a difficult and frustrating decade for thoracic surgeons. Physician payment reform for the Medicare program, which was first proposed in the 1980s, was legislated by Congress in 1989, and implemented in stages beginning in 1992. As a result of this process, thoracic surgeons have experienced substantial reductions in reimbursement for their professional services to Medicare patients. We previously reviewed the health policy and legislative history of Medicare physician payment reform [1]. In that paper, we described the resource-based methodology that has been developed and used for the determination of physician work levels and that has so adversely affected surgical specialists. More recently, many of our professional organizations have attempted to mitigate further reductions that are occurring now because of changes to the practice expense component of the Medicare fee schedule. Unfortunately, we can expect additional reductions due to the final phasing-in of the new Medicare professional fees.
We were especially disappointed in November 1999, when the Health Care Financing Administration (HCFA) altered its practice expense guidelines and disallowed the costs incurred by specialists’ clinical staff, such as a physician assistant, when assisting the surgeon in the hospital. Anesthesiologists, gastroenterologists, cardiologists, and many other hospital-based specialists who use their own employed staff in hospitals also are being penalized by this policy. This decision adds substantially to the frustration of cardiothoracic surgeons who have experienced such demoralizing decline in support for their care of Medicare beneficiaries.
I have been asked repeatedly over the past several years by many colleagues how much more reduction can be expected from Medicare physician payment reform. We are asked, especially after this most recent policy interpretation, whether HCFA intends to continue to reduce its support for hospital-based specialists. Is there a floor below which reimbursement rates cannot be driven? Perhaps the most difficult question to answer convincingly and one that is raised repeatedly is, "What can we do to stop this unfair treatment?"
Everyone in medicine has had to deal with the consequences of declining support for physicians in the Medicare program, but there has been a disproportionate decline experienced by specialists. Some thoracic surgeons believe that the costs incurred while caring for some Medicare patients will exceed what is provided by the program. Many wonder whether we will be able to continue to treat many of the most difficult patients when to do so will result in financial losses. Furthermore, the Medicare program’s resource-based method for determining physician reimbursement is being adopted widely by commercial health insurers and concern for future economic survival deepens. We worry not only about whether we can afford to provide thoracic surgery care for patients in the future but we are also concerned about why anyone would aspire to become a thoracic surgeon under these evolving circumstances. Many believe that the length of training required, the personal demands of thoracic surgery practice, and the level of society’s expectations for perfect outcomes, combined now with severe reductions in physician support, will deter many bright young people who in the past have aspired in such numbers to this respected specialty. Even the optimists among us are shaken by what appears to be erosion of the respect and esteem of our fellow citizens that thoracic surgeons enjoyed in the past when our professional work was more appropriately valued. Why has this happened to our specialty? Is there anything that we can do about it in the future?
Public policy and health economics experts have declared for 20 or more years that funding for the Medicare program has been growing exponentially and is out of control. Advancements in medical technology and the aging of the population with steady increases in the number of eligible Medicare recipients prompted planning for aggressive Medicare reform, especially in the 1980s when the U.S. government tightened its belt under the economic reforms of the Reagan administration. The prospective method for reimbursing hospitals, based on diagnostic-related groups (DRG) of medical conditions, was instituted in the late 1980s. Physician payment reform with cuts to the Medicare fee schedule in Part B of the program began in earnest in 1992.
Although we are nearly finished with the changes mandated by law, we will see further reductions from phased-in transitions to even lower fees through 2002. In addition, increases in the Medicare-eligible population and the anticipated increases in the utilization of services by Medicare recipients will result in further reductions in payments to all physicians. Congress has effectively capped annual Medicare spending. The variable conversion factor, which determines the reimbursement level for each resource-based Medicare service, will be lowered annually as total Medicare services increase.
The dynamics of the process that has brought us to the current conundrum of declining support for specialty medical care are complex and often misunderstood. HCFA, especially the agency’s leaders and those professionals who work in the physician payment area, are felt by many to be responsible for our severe fee payment reductions. Although HCFA leadership has had a greater role than simply being messengers in this reform process, the real problem lies in the legislative branch of government, with members of congress and their advisors who are responsible for the current U.S. health policy. Central to this policy is guaranteed medical support and care for all older citizens and for many others who are permanently disabled. Congress imposed a ceiling on expenditures for the Medicare program based on projections that the spiraling costs of medical care would destroy the federal budget. Key to understanding the process of physician payment reform in the Medicare program is the fact that it has been legislated by Congress and is simply administered by HCFA.
Actual responsibility for Medicare program reform, however, is very difficult to ascribe. When one questions individual members of Congress, even those on Congressional committees responsible for the oversight of HCFA and the Medicare program, the legislator will point to the health policy community and congressional advisory groups as the source of the Medicare program reform policies. The Physician Payment Reform Commission (PPRC) and its successor group, the Medicare Payment Advisory Commission (MedPAC), were established to provide Congress with health policy and health economic advice. Such experts in the past urged Congress to move from cost-based to resource-based economic analysis for physician service payments. Reform of the physician work component of Medicare fee schedule using a resource-based or effort-linked methodology was the result of the Harvard School of Public Health study conducted by William Hsiao and his team in the late 1980s [2]. We have been assured that this economic modeling system, adopted by HCFA as its method for physician payment reform, is the fairest and best possible solution.
While Medicare payment reform has proceeded, Congress has legislated that participation in the Medicare program is required of any physician who cares for Medicare-eligible patients. Congress has also decided that physician payment formulas will be determined and adjudicated by HCFA. Philosophically, this program seems to contradict the open economic principles of our society. We are told that such government "price controls" are acceptable in this case: our older citizens are entitled to full equality of health care, and the federal government is responsible for assuring this care. We can find, however, much to criticize in HCFA’s administration of the Medicare program, especially for what are seen as policy decisions prejudicial toward hospital-based physicians and other specialists.
How should thoracic surgeons respond to such changes imposed by Medicare program reform? The option of absenting ourselves from the Medicare program in any sort of collective fashion is neither legally feasible nor professionally appropriate. Although it is possible to put together some physician bargaining groups, as the AMA has agreed to support, Congress has made it impossible for us to opt out of the Medicare program and still serve the elderly population. If individual thoracic surgeons or groups find that caring for Medicare patients results in unsustainable financial losses, inability or unwillingness to assume care for such patients may result. Imagine the dilemma posed by the need to provide emergency or urgent care, as we do so often already, even when break-even support can not be achieved.
How can our concerns be heard? Can we reverse these unfavorable actions of Congress and HCFA? We must continue to engage HCFA’s analysts and policy makers over issues where we have been unfairly disadvantaged by HCFA’s policies. We must be well represented in forums such as the Relative Value Update Committee, the Practice Expense Advisory Committee, and other multispecialty groups that interact with HCFA. We must engage members of Congress and their staff, and through them, policy-making congressional committees. Through the Washington STS office, under Robert Wilbur’s direction, and with legislative and public affairs consultants, we have been successful over the past several years in establishing a presence in Washington. Whether we are comfortable with or approve of the process of government lobbying, we will not have our grievances with the Medicare reform process addressed by members of Congress without interacting with the appropriate senator and representatives, their staff, and with the responsible congressional committees.
Physicians have the reputation of being poor political supporters and contributors to legislators who require the financial support of interested citizens to deal with the challenges of elective office. Another troubling fact is the absence of specialty-oriented health policy advocates and experts in Washington. Physicians who have been well represented and most active at the interface with government and the health policy community have belonged to primary care organizations. Because these physicians, in fact, make up the bulk of medical practitioners in the country, their influence has been disproportionate on members of Congress and in the health policy community.
Another peculiarity of the political process and of our interactions with HCFA has been the lack of consensus achieved by medical specialists who are especially disadvantaged in the reform process. Primary care specialists, who include family practice physicians, internists, pediatricians, and to some extent specialists such as psychiatrists who are predominantly outpatient office-based, appear to be more effective in achieving consensus of interest when attempting to influence HCFA policy and regulations. Many specialists, on the other hand, predominantly surgeons and others such as gastroenterologists, interventional cardiologists, and anesthesiologists, have not come together as effective political advocacy groups. There was an informal surgery caucus in the early days of the AMA RUC process. Practice expense reform, however, which has been beneficial to surgical specialists that are predominately office based, has resulted in loss of a unifying surgery position.
As we move forward, we need to encourage many members of our specialty to become involved in the health policy and legislative areas in order to give us the visibility and credibility in Washington that we have not had in the past. We need to be able to match the effectiveness that some medical and other special-interest groups have been able to achieve when vying for the attention and support of Congress and of the federal regulatory agencies. We must participate in the political process as supporters, contributors, experts, and petitioners. We have to coalesce politically as a specialty and work effectively to achieve consensus among other adversely affected specialty groups.
In addition to existing problems with the Medicare program and with the physician payment reform process that need to be addressed and corrected, we also must be concerned about sustaining the same level of health care and innovation for the Medicare program in the future. Every serious discussion in Washington about basic Medicare program reform has been stymied by political pressure on Congress and members of the Executive branch of government by citizens who are unwilling to consider losing any existing benefit. Attempts to reduce Medicare expenses by stratifying benefits on the basis of need are proposed only at great political risk by elected officials. With Medicare utilization increasing and with support for the Medicare program limited or capped, the capability of introducing new technology and other medical advances into the program is threatened. HCFA’s unwillingness to approve lung volume reduction procedures for Medicare recipients should be viewed as a harbinger of how the agency will deal with other new therapies, both medical and surgical, that technically can be termed experimental.
We can look to our professional societies, such as The Society of Thoracic Surgeons and the American College of Surgeons, and to health advocacy organizations like the American Heart Association, to lead the way in Washington and in state capitals on behalf of our health care system. There is no substitute, however, for the importance and potential effectiveness of sustained, well-informed, and personal political activity on our own behalf. We have a "cause" for which our activities are eminently justifiable: we want to ensure that the medical advances of the last several decades are sustained and continue to be available to all of our citizens. We also want to ensure that the extraordinary pace and scope of medical advances that we are experiencing now will continue for future generations. We should be strong and vocal participants in the public policy deliberations about how to fund future health care, whether to ration care, and how to value improvements in health care in comparison with other goals for our society. Thoracic surgeons cannot afford to spend all of our time in our clinical efforts. We can not rely on others to promote our values and interests in a political arena full of other worthy social goals.
We have experienced virtually unbelievable advances in thoracic surgery during the last 50 years. Most of us cannot even envision what future opportunities exist for our specialty. We must not allow these opportunities to be limited because of our failure to promote thoracic surgery in the public forum of this participatory democracy. Each of us should put aside some portion of our professional time for education of the public and for effective political action.
References
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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 A. G. Little Invited commentary Ann. Thorac. Surg., January 1, 2001; 71(1): 12 - 13. [Full Text] [PDF]
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