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Ann Thorac Surg 2007;83:9-11
© 2007 The Society of Thoracic Surgeons
a President, The Society of Thoracic Surgeons, Chicago, Illinois
b Department of Surgery, University of Colorado Health Sciences Center, Denver, Colorado
* Address correspondence to Dr Grover, Department of Surgery, University of Colorado Health Sciences Center, 4200 East Ninth Ave, C-305, Denver, CO 80262 (Email: frederick.grover{at}uchsc.edu).
The article by Dr Peter K. Smith and his colleagues in this issue of The Annals of Thoracic Surgery [1] reports good news: the Center for Medicare & Medicaid Service (CMS) has recognized the actual time and intensity of cardiothoracic surgeons’ work. This recognition provides a more accurate valuation of our work and the results have produced substantial increases in cardiothoracic surgeon work values for the most frequently performed cardiac and general thoracic surgical procedures. This progress in rectifying inequities in reimbursement represents a dividend from The Society of Thoracic Surgeons’ (STS) investments in creating and maintaining our three national databases to replace guesswork estimates with actual data and the hundreds of hours spent by STS members in working with members of Congress, federal agencies and colleagues in other medical disciplines. At last, long-standing inequities in determining the relative value of our work have been heard.
As President of the STS, I would like to take this opportunity to comment on our recent efforts to achieve accurate, fair reimbursement for cardiothoracic procedures as outlined in the following article by Dr Smith and colleagues [1]. The results are exciting and represent a true paradigm shift in reimbursement methodology. While these efforts deserve congratulatory recognition, there is much more that each of us can and should do.
In 2005, Medicare spent approximately 61.5 billion dollars to reimburse physician services. With such a huge dollar amount at stake, one would expect that the process to distribute these funds would be a fair one, based on a scientific method using real data and objective analysis of time, effort, and expense. Although the original Resource Based Relative Value Scale (RBRVS) was intended to do just that, the current system of valuation which evolved following RBRVS has little to do with any objective scientific method. Currently, the billions of dollars Medicare pays for physician services are apportioned on the basis of the amount of physician work assigned to each service; these work values are in turn based solely on "guesstimates" provided by small numbers (usually around thirty) of nonrandomly selected specialty practitioners. Best estimates are provided by these physicians regarding the time and effort involved for each Current Procedural Terminology (CPT) code they perform. The resulting values are tabulated and the results adjudicated by the Relative Value Update Committee (RUC). The RUC is an American Medical Association (AMA)-sponsored subcommittee composed of 29 members of various specialties whose mission is to determine the correct value of relative physician work for each code. Although the AMA feels that this system is currently the most fair method for apportioning funds, the process is methodologically suboptimal. It is rife with opportunities for conscious and/or unconscious bias on the part of both specialty survey respondents and the members of the multispecialty RUC committee. In short, the process is subjective, involves no real clinical data, and is subject to both manipulation and politicization.
In this particular year of the 5-year RUC Review, the STS, under Dr Smith and his colleagues’ leadership, promoted use of the STS Databases as a more objective method for evaluating cardiothoracic surgeon time spent during the operative procedure and the postoperative period including ICU critical care and the total hospital stay. In addition, they utilized the STS Cardiac Surgical Database to supply evidence of increasingly higher risk patients to demonstrate an increase in the surgical effort required for their care. The success of this program and new methodology as described in this paper is a landmark and paradigm shift for the RUC-CMS Process that introduces the use of objective data rather than the usual physician survey subjective data which can be incorrect and self serving. In addition, our STS/AATS (American Association for Thoracic Surgery) Workforce on Nomenclature and Coding succeeded in convincing the RUC Committee and CMS that mean values rather than median values were more reflective of surgeon work effort and that patients with long operative times and lengths of stay were real and needed to be accounted for. This group also spent a great amount of time and effort in arguing successfully for the incorporation of the critical care component in the global fee for cardiothoracic surgeons. The Database enhanced this valuation by demonstrating the time of the ICU critical care stay. One criticism of the use of the STS Database in this process was that very few specialties are in a position to utilize objective data from databases because they have not spent the time and money to do so. It was our group’s feeling, however, that cardiothoracic surgeons should lead the way in this paradigm shift in methodology and hopefully stimulate other specialties to follow suit which should produce a more fair process.
In summary, the major points were:
As described in the paper, there were many hours of vigorous debate at the RUC level which eventually resulted in a two-thirds majority vote in favor of the STS/AATS methodology. This was surprisingly rejected in June by CMS, partly because of the fact that other specialties were not able to utilize the database methodology. However, Dr Smith and his colleagues were very persistent and dedicated and presented a 54-page rebuttal and met with CMS again. In a very unusual event, CMS in November reversed its original decision accepting the STS/AATS RUC recommendations.
In reversing its previous stance in November, the CMS final rule noted, "The commentators provided additional detailed information concerning the STS Database, as well as their use of mean values for the intraservice time and the intensity methods used to estimate Intraservice Work Per Unit Time (IWPUT). ... We believe the STS Database represents a significant advance in the effort to improve the quality of patient care and we hope that this kind of data collection will be emulated by other specialties. We also believe that the time and visit data contained in this database could be useful adjunct to the RUC’s validation of the standard RUC survey results. ... Based upon a review of the specific information provided by the commentators concerning the STS Database, as well as the information provided specifically addressing the use of the mean values for the intraservice time and methodology used to estimate IWPUT, we will accept the RUC recommended work RVU’s for these services."
I would like to express my appreciation to the RUC members from other specialties for being open minded and supporting this change in methodology. I would also like to compliment CMS for having the courage to reverse its June decision because it is very unusual after a public statement and stance that an organization would listen objectively to the evidence and reconsider and reverse its decision.
It must be emphasized that our volunteers put in thousands of hours of volunteer time and were very innovative and thoughtful in this process and all of us need to be very grateful for this Herculean effort on their part. The result of all of this is that there was a 12.3% increase across the board for cardiothoracic procedure reimbursement. For Medicare patients only this will be 4.8% increase. This is still a very significant increase, particularly when many specialty groups received a decrease. Still ahead of us is the proposed reduction in Medicare reimbursement across all specialties of 5.1%. This is based on the Sustainable Growth Rate (SGR) formula. We are hopeful that with an effort similar to that of the RUC effort that we can be instrumental in getting Congress to reverse this pending cut which is due to take place in January.
One of the primary reasons reimbursement to cardiothoracic surgeons is so important is the fact that we are not filling all of our residency positions and have a major workforce shortage predicted by 2020 to be as much as 40% in an analysis performed by the American Association of Medical Colleges (AAMC) [2]. This will have a terribly negative effect on cardiothoracic patients’ access to care and quality of care. Although there are a number of factors related to one’s choice in choosing cardiothoracic surgery as a profession, the fact that we have seen draconian and inexplicable cuts in reimbursement of upwards of 50% over the past 10 years has to play some role. This coupled with the fact that the average debt of graduating medical students is over $100,000, that the length of the combined general surgery and cardiothoracic surgery residencies is anywhere from 7 to 10 years and that cardiothoracic practice after residency, although very rewarding, because of its nature of taking care of critically ill patients, is also very demanding with an average work week of 67 hours [3]. It is therefore mandatory that we strive to obtain fair reimbursement for cardiothoracic surgeons, taking into account the length of training and the challenging patient population that we care for. This is a major national health care issue that cannot and will not be underestimated.
There are several issues that trouble me. The successful efforts outlined above cost the STS over $150,000 over the past 12 months and required literally thousands of volunteer hours of work by many STS members. While it is appropriate to celebrate these efforts, our experience from the 5-year review also provides cause for concern. While the STS National Cardiac Database was mature, robust and replete with patient information, the General Thoracic Database and Congenital Heart Database contained patient numbers and practitioner participation rates that were pale by comparison. If we are to continue to succeed in accurate valuation efforts in the future, all STS members must participate in the appropriate databases, and this must begin immediately. The inexorable movement towards Pay for Performance (P4P) both in Congress and at CMS accentuates the importance of database participation. P4P will be enacted soon in some form and will probably result in economic penalties for those not submitting data to a recognized database. In short, STS members must join and actively participate in the STS databases; failure to do so will likely exact a serious cost both to the individual practitioner and the thoracic community as a whole.
Yet another issue is the ongoing political effort of the STS, attempting to effect change in the areas of quality assessment, practice expense reimbursement, liability reform and replacement of the current Medicare Sustainable Growth Rate (SGR), a methodology which cripples the just compensation efforts for all of medicine. There is great hope that we can achieve success in these areas, just as we have with reimbursement. However, these issues can be effectively addressed only with the participation of the entire STS membership. The alarming reality is that a significant fraction of our membership is unengaged and does not participate. Appeals to our membership requesting them to write letters to Congress (a 3-minute task on the STS website), participate in surveys, or contribute to the STS Political Action Committee (PAC) routinely result in the participation of fewer than one third of our members. While this may be ascribed to burgeoning paperwork, an increased clinical workload, or simply poor interoffice communication, the results are no less damaging. The willingness of such nonparticipants to allow their colleagues to shoulder the entire burden is disconcerting and certainly not befitting a specialty which prides itself on initiative, personal responsibility, and the ability to truly "make a difference." If the progress in reimbursement evidenced above is to continue in these other arenas, it will require the active participation of all active STS members in ongoing efforts towards political reform. If our specialty is to thrive, recruit the best and brightest, and offer the highest quality patient care, all of us must be involved by:
If we all accomplish the above, we can expect continued success in STS efforts to protect and improve our specialty and the care that we deliver to our patients.
Many thanks to all of you who have volunteered your valuable time and resources to this effort.
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  M. B. Ratcliffe, C. Howard, M. Mann, and P. del Nido National Institutes of Health funding for cardiothoracic surgical research. J. Thorac. Cardiovasc. Surg., August 1, 2008; 136(2): 392 - 397. [Abstract] [Full Text] [PDF]
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