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Department of Cardiovascular Surgery, Children's Hospital, Harvard Medical School, Boston, Massachusetts
* Address correspondence to Dr Mayer Jr, Children's Hospital, Harvard Medical School, 300 Longwood Ave, Boston, MA 02115 (Email: john.mayer{at}cardio.chboston.org).
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In preparing this address, I reviewed the STS presidential addresses for the last 10 years. I found it interesting that the issues George Kaiser [1] thought we were facing in 1998 are not very different from those we face today, issues of regulation and loss of autonomy and control over how patients are cared for, external scrutiny and accountability, funding issues and the costs of health care, and new technology and therapies and their implications for surgical practice. The titles of several popular books from that time frame are of interest: Why We Spend Too Much on Health Care and What We Can Do About It [2], Medicine at the Crossroads: The Crisis in Health Care [3], and Strong Medicine: America spends more on health care than any other nation, and we get what we pay for. The problem is that it isn't what we want or need or could be getting [4]. All of these books, and numerous others about the how the American health care system was too expensive and inefficient, were written in the early 1990s, but they are echoed in the health care issues we are hearing about today in the press and in the political arena.
In the middle to late 1990s, the focus shifted to raising major questions about the quality of the care we deliver. We had books in the popular press such as Demanding Medical Excellence [5] by a Chicago Tribune reporter suggesting that patients had to "demand excellence from physicians," and we even had a Presidential Commission outlining the problems with the quality of care our patients were receiving [6]. And then we had the first of several reports from the Institute of Medicine including "To Err is Human" [7] and then "Crossing the Quality Chasm" [8].
There is no doubt this focus on health care quality and safety was in some ways justified, and we certainly needed to improve our systems of care to achieve better outcomes. We all are experiencing an emphasis on these areas of quality and patient safety in our own institutions every day. But at some level, I think all of us have been a little offended by this public perception and continuing portrayal in the press that what we physicians were doing was too expensive, too inefficient, and not safe. In cardiothoracic surgery, in particular, we have improved outcomes despite an older, sicker patient population, and yet Medicare reimbursement has been reduced. Much still seems beyond our control and is being imposed on us from outside.
In attempting to understand how this is happening and why it is causing so much distress and emotional dissonance within medicine, I believe it is important to focus on what it means to be a member of a profession and to then put forward some ideas about how some of our perceived problems can be approached by returning to some of our professional roots.
There is a rich literature on professions and their relationship to society. One definition comes from The Osler Fellows Program at McGill University [9]. A profession is an occupation whose core element is work based upon the mastery of a complex body of knowledge and skills. It is a vocation in which the knowledge of some department of science or learning or the practice of an art founded upon that science is used in the service of others. Its members are governed by codes of ethics and profess a commitment to competence, integrity and morality, altruism, and to the promotion of the public good within their domain.
Others, including Justice Brandeis, described other elements of a profession, including advancement of a body of knowledge and transmission of this knowledge to future generations, and cherishing performance above personal rewards [10]. Others have emphasized the moral commitment involved in being a member of a profession [11].
It is important to recognize that we actually have two different but highly interrelated roles: One is to be a healer of the sick, and the second is to be a member of a profession. The concept of being a healer of the sick dates back to antiquity and the Hippocratic Oath we all took upon graduation from medical school. The second role is that of a professional, a concept that dates from much later in history, from the Middle Ages, and encompasses other "learned professions," including the clergy and the law as well as medicine [9].
I believe all of us think our primary role is as a healer, or as Richard Anderson described it in 1999, "applying the hand work and the mind work of surgery in the care of the sick" [12]. It is clear these roles as healer and as a member of a profession overlap and are very much interrelated. In fact, it has been argued that the concept of a profession is actually a societal construct, something society uses to organize the services provided by the members of a profession, in our case, healing of the sick.
Society could choose other models but, arguably, has not chosen to do so until recently because of the risk of undermining the healing function the physician and surgeon provide. It is my sense that many of the concerns we are feeling are the result of elements of both the bureaucratic and free market models being introduced into our relationship, between our profession and the society we serve.
What governs the relationship between our profession and society is a social contract that, unfortunately, is largely unwritten and yet contains expectations and obligations between physicians and patients and between society and the medical profession [9]. Society expects us to be competent, altruistic, objective healers who act with integrity and honesty and who will also promote the public good [9]. Society also now expects accountability and transparency.
In return, physicians expect to be trusted, to be allowed to function without external control, to be allowed to self-regulate, and to participate in a health care system that is driven by values and is adequately funded [9]. Physicians also expect to be financially rewarded in a reasonable fashion and to have a respected place in society [9]. Finally, physicians should expect to have a role in public policy as it relates to the delivery of medical care.
I would argue that it is in this sphere of the social contract between the professions and society where our biggest problems lie, particularly in the areas of autonomy and self-regulation, but also in the areas of trust and reward. The social contract that defines this relationship between the medical profession and society is much like a partnership. Successful partnerships depend on trust, mutual respect, and communication. In fact, professions, with their prerogatives and privileges, are protected from the forces of the free market by society only so long as society trusts that the profession is acting in the societal interest and not its own [13]. Based on several conversations I have had with members of Congress and the Executive Branch of the federal government, I do not think there is a high level of trust in the medical profession as a whole, although most say they trust their own doctors.
What forces have been unraveling this social contract between medicine and society? There is little doubt that health care has become a big business, by some estimates comprising as much as one-seventh of the US economy. The author of Critical Condition: How Health Care in America Became Big Business—And Bad Medicine [14] clearly concluded that this change has not had a positive effect on how medical care is delivered. I doubt the corporatization of health care can be stopped. However, we must work as hard as we can to prevent the negative effects of these changes on how we function as healers of the sick and members of a profession.
Others have raised fundamental questions about medicine as a moral undertaking, including Marc Rodwin in his book, Medicine Money & Morals: Physicians' Conflicts of Interest [15]. The chapter titles in this book are revealing and are focused on the conflicts of interest physicians face as a result of various economic mechanisms that have been introduced into the health care system in an attempt to influence physician behavior. This focus on physicians' conflict of interest carries the implication that financial incentives are influencing the individual physician's treatment of individual patients. We also have to recognize that there is a perception both in Washington and elsewhere that physicians have unduly benefited from the guaranteed payment provisions in the Medicare system [16]. We cannot afford these types of public perceptions if we are to survive as a profession.
At the same time, society has used governmental regulatory power, the so-called bureaucratic model, to drive down the reimbursement for procedures that cardiothoracic surgeons perform, including 3-vessel coronary bypass, aortic valve replacement, and lobectomy. It is my sense that our largely unwritten social contract is unraveling, probably with blame assignable on all sides. It is easy for us to blame the perverse aspects of the reimbursement system, or the corporatization of health care, or the lay press for our dissatisfactions with the health care system, and I think some changes to the reimbursement system could be made to better align the incentives. However, I do not think this is where we should start. I believe it is critical to focus on rebuilding the mutual trust and sense of partnership between medicine as a profession and society, because this mutual trust and sense of partnership is ultimately the basis for the social contract between medicine and society.
Many efforts are underway directed at rebuilding this trust. The STS, as well as many individual surgeon-members, have engaged in a number of initiatives for our profession that have served to improve our standing in the eyes of the public and have served to start rebuilding public trust. Of all of those efforts, the STS Database is among the most notable. As many of you know, the STS started the National Cardiac Database in the late 1980s and began gathering data on adult cardiac surgery outcomes and feeding it back to the individual practices and institutions as a tool for improving outcomes. This effort has grown remarkably and has been accompanied by a progressive decrease in the ratio of observed to expected mortality for coronary bypass. There has been a progressive rise in the use of internal mammary artery grafts, which have higher long-term patency and better outcomes for patients. In a prospective trial led by Bruce Ferguson, the database served as the vehicle to increase use of β-blockers and the use of internal mammary artery grafts in the elderly [17].
The Northern New England Cardiovascular Study Group, which started before the STS database in the mid-1980s, has used the same central collection of data, risk-adjustment, and data feedback methods but added the important additional dimension of regional cooperation and collaboration, including round-robin visits in each other's operating rooms. Their efforts resulted in reductions in the mortality rates for coronary artery bypass grafting and in the incidence of fatal low cardiac output after coronary operations, well before the national focus on quality and patient safety [18]. The mortality reductions were as good, if not better, than those in New York state during the same time, without putting individual surgeons' names across the front page of the New York Times.
More recently, the Virginia Cardiac Surgical Quality Initiative, led by Jeff Rich and his colleagues in the cardiac programs across the state, have looked at both clinical outcomes, based on the STS database, and financial outcomes for cardiac surgical procedures. They were able to identify the incremental costs for postoperative complications and showed that statewide collaborative efforts, learning from each other, could lead to both improved outcomes and reduced costs while still maintaining better mortality results than what would have been predicted. The postoperative incidence of both mediastinitis and atrial fibrillation was reduced by the efforts of the Virginia group. If you extrapolate out the potential nationwide cost-savings to the Medicare program by reducing postoperative complications, you start to see some pretty sizeable savings. These findings were very well received and started changing some minds when Dr Rich testified in front of a Congressional committee in 2007 [19].
The STS has also used the database to engage with the National Quality Forum (NQF) to define performance measures that are now the standard for evaluating cardiac surgical outcomes nationally. The fact that the STS was the first specialty society to go through the NQF process and that almost all of the outcome measures for cardiac surgery come from the STS database has been widely noted and appreciated in the halls of government. The database has now become a central part of a variety of efforts, including those in Michigan, where Blue Cross is now funding a cardiac surgery quality improvement initiative across the entire state to the tune of several million dollars and is working with the Michigan cardiac surgeons and using the data they submit to the STS database.
There are other developments with the database, including a major effort to have it link to other data sources so longitudinal follow-up information and cost information can be linked to our already robust clinical data. By collecting unique patient identifiers, we can link to and draw information from the National Death Index and the Medicare database to obtain long-term survival information. We are also in active discussions with the American College of Cardiology to link up with its interventional catheterization database. This linkage will allow us to follow patients who undergo both catheterization and surgical procedures over time. In the pediatric cardiac area, we are working with the pediatric cardiac anesthesia society, we are adding an anesthesia module to the congenital cardiac database, and we are working on links to the pediatric critical care database.
The fact that the STS adult cardiac database now has more than 3 million patients entered, that more than 80% of the adult cardiac surgical centers and more than 50% of the pediatric centers are now participating in the database, that the database is now audited, and that there is evidence that the database mechanism is effective as a tool for improving outcomes and reducing complications and their related costs has gone a significant way toward improving our credibility in Washington and with the private payer community.
These ideas are now catching on elsewhere in medicine. The American College of Cardiology has established a database for interventional catheterization procedures and has undertaken an initiative to reduce door-to-balloon time for patients with acute myocardial infarctions. They have been able to reduce the door-to-balloon time by tracking these times and feeding the information back to the local level with comparisons to national benchmarks.
The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) is also being expanded beyond the Veterans Affairs hospital system, where it was very effective in improving outcomes [20]. We should not forget how the STS database provided essential information for the last 5-year review at the relative value update committee and actually changed the paradigm at that committee for how physician services are valued from "magnitude estimation" to a process that is much more dependent on real data [21]. There were significant increases in the values for many cardiothoracic surgical procedures, and the overall impact was significant, with estimated increases in overall Medicare reimbursement of nearly 5% and an estimated overall impact across all payers of more than 12%.
The database has also become important in responding to the latest new idea to fix health care that has been referred to as pay for performance. The obvious problem is how to assess performance. Using the STS database, we have developed a methodology to do this, but few other specialties are in a position to do so. Instead, we have advocated for pay for participation, and by that I mean participation in efforts such as the STS databases that involve the processes of data collection, central risk adjustment, and feedback to the individual practice and physician level.
It is now part of federal law that participation efforts such as the STS database will become part of the physician quality reporting initiative under the Medicare program in 2009, and this will result in a much easier way to qualify for an increase in reimbursement of 1.5% for all Medicare services provided by the participating surgeon. Although the 1.5% Medicare bonus will not be a large amount of money, it is conceptually important because we have been able to shift the conversation away from pay for performance and toward payment for participation in a process that helps to improve patient outcomes and helps physicians fulfill their professional responsibilities. Blue Cross is now requiring database participation for its Blue Distinction program, and other national payers are considering similar requirements.
This shift was possible because we had the evidence to make the case in Congress that database participation could result in improvements in patient outcomes and that a specialty should be recognized and not penalized for engaging in professional behavior. Parenthetically, I should add that we cannot underestimate the importance of your contributions to the STS Political Action Committee (PAC) in providing access to members of Congress where we can have these policy conversations.
All of these efforts have almost certainly helped to improve the perceptions, at least of cardiothoracic surgeons, in Washington and have served to move some distance toward regaining societal trust. Will this be enough to truly bring our professional responsibilities into line with the interests of society and also have more of our expectations of society met? I think it will also require some significant structural changes to the reimbursement system, and I would like to offer a few ideas about how to change certain parts of this system to more closely align the financial incentives for our specialty with our professional responsibilities to society, without compromising our ability to fulfill our healing function.
I believe we should start with the Medicare reimbursement system. Medicare, as all of you know, is important for adult cardiac and thoracic surgeons because of the patient population we see, but its influence extends far beyond the over-65 population. Recent figures suggest that more than 70% of the private payers in the United States use the Medicare Fee Schedule as the basis for some or all of their fee schedules [22]. To start, I wish to point out some fundamental conceptual problems that are built-in to the Medicare reimbursement system.
First, we have to remember that under the sustainable growth rate formula for Medicare, the entire pool of resources from which all physician reimbursement is drawn is essentially a fixed pie that grows only as fast as the Medicare population increases. The growth of the pool also depends on the growth of the economy. It is what is known in game theory as a zero-sum game. The only economic reward for the physician in this system is to provide more services or higher complexity services, and when any physician group's total volume of services grows faster relative to the others, every other physician's reimbursement is adversely affected.
I mentioned game theory, and there is a game theory description of what happens under these zero-sum game circumstances. In Micromotives and Macrobehaviors, by the recent Nobel Prize winner Thomas Schelling, the effect of a zero-sum game is that "In maximizing their own benefit, the participants impinge on each other, despite the fact that they might be better off if they could be restrained, but no one gains individually by self-restraint" [23]. This phenomenon is exactly what has happened with Medicare physician services: The growth in the volume of services continues to go up, and the Medicare conversion factor goes down the next year, unless Congress intervenes.
A second conceptual flaw is the assumption that because "overspending" this year will lead to a reduced Medicare conversion factor and reduced reimbursement next year, individual physician behavior would actually be affected. I doubt any physician considers this effect on future reimbursement from the Medicare system when considering whether to see another patient in the office or to do another operation. The recurring Medicare physician payment crises that have occurred for the last several years with threatened cuts in reimbursement averted only by last minute Congressional interventions is further evidence that this whole system is conceptually flawed.
Finally, there is no incentive for the profession to engage in any self-regulation in this system, and there is no incentive to improve quality. Many specialty societies are preoccupied with advocacy related to reimbursement, and few have engaged in the types of database and quality improvement activities that the STS has. It is not difficult to determine why an emphasis on advocacy on reimbursement issues has been the focus of most medical specialty societies.
Can simple economic incentives work? I think American society has tried the capitation/managed care approach, which suffers from the problem that the individual physician or practice is being pulled in opposite directions by personal benefit incentives and patient benefit obligations. The strong negative public reaction to the whole idea of capitation at the individual physician or practice level is evidence that this is a failed concept. No one trusted that the physician's financial welfare was not influencing patient care under capitation.
Does this mean that reimbursement and economic incentives must remain completely divorced from any influence on physicians? I do not think so. I would argue that the point where the economic incentives should be focused is simply at a different level than the individual physician or practice. Rather, the incentives should encourage physicians to act as members of a profession, which is where critical parts of the social contract exist. I think this can best be accomplished at the specialty level. Many of these ideas are outlined in an editorial published in The Annals of Thoracic Surgery in 2007 [24].
I would start by creating specialty-specific conversion factors rather than the single conversion factor that currently exists for all of medicine. As I noted, the current system rewards only those physicians and specialties that increase the volume and complexity of services that are provided. Any specialty that practices more effective medicine, which could actually reduce the volume of services that are provided, is currently penalized by the increased reimbursement to all of the other specialties that have an increase in volume.
In the current Medicare system, the economic incentives to increase volume of services pull in a direction opposite to our professional responsibilities to society to wisely allocate health care dollars and to practice more effective medicine. Specialty-specific conversion factors would provide an incentive for the entire specialty to work together, to self-regulate, and to try to determine best practices based on data from outcomes-focused registries. These collective efforts by the entire specialty would not be penalized, and if the aggregate volume of services decreased and outcomes improved, all members of the specialty would see an increase in the conversion factor and increased reimbursement per procedure for the entire specialty.
Some have argued that such a system would lead to a further fragmentation of health care or would pit specialties against one another. I would argue that it is at the level of the individual professional society, where organizational structures like the STS database exist, that we also find a natural alignment of physicians' interests and the potential for the peer pressure and expertise required for self-regulation, to be brought to bear. The STS experience with regional and national data collection, risk adjustment, and data feedback indicate it is at the specialty level that collaboration and sharing of information can best be accomplished. There are other alternatives, one of which might be to redo the Medicare experiment of 10 or 12 years ago in which global payments were made to hospitals and physicians for major procedures. The problem with this approach is that it only covers a small part of the total physicians' services that are being paid for under Medicare.
The second change I would propose is increased support and financial recognition for outcomes-focused databases such as the STS database, the American College of Cardiology's interventional catheterization registry, and the American College of Surgeons NSQIP registry. The potential 1.5% bonus for reporting outcomes to such a registry is a drop in the bucket compared with what database participants spend to participate and what the STS spends to maintain the database. On the other hand, I personally believe this kind of support would be a very inexpensive investment for American society to make, with a potentially huge return on investment if the extrapolations from the Virginia experience are any indicator.
Finally, we will have to begin to do more to self-regulate. I think we all are motivated by seeing our own risk-adjusted data from the database that shows how we compare with our peers across the country, but despite the evidence that shows that outcomes improve, it is probably not enough to convince those in government and in the payer community to leave self-regulation to us alone. The STS quality measurement task force has developed a composite measure of performance based on both outcome and process measures that were approved through the NQF process [25]. Our challenge is to learn from those physicians and practices on the high performance end of this curve and to help those on the other end.
To pursue this goal, we have recently set up a STS workforce on peer review, which is completely separate from the Standards and Ethics Committee. This workforce is available for any surgeon, practice, or institution to use as a resource. The intent is to make the width of this distribution curve as narrow as possible, to raise the level of care in every institution in the country, and not to profile. If we approach this from the perspective of the patient, I think that is what we would want, higher-quality care everywhere.
This new reality will also require that we rethink how we relate to one another as members of the same profession. In the current environment where the conventional wisdom is that "competition" and "the forces of the market" are the solution to improving health care costs and improving quality, we are all under pressure to compete with one another. It is difficult to reconcile competition with professional collaboration. And yet, I believe it is our collective professional responsibility to improve the care of the sick, and this involves learning from one another. Are we in a unique position in regard to the potentially conflicting requirements to compete and to collaborate?
There actually is a model for both collaborating and competing, which is described in Co-opetition, appropriately, a book written by authors from the Yale School of Management and the Harvard Business School [26] who show how it is possible that one's competitors can also be one's complementors. I believe that it is critical that we not allow the pressure to "compete" to dominate our ability to collaborate and to fulfill our responsibilities to our patients, to our profession, and to society. There are many ways of viewing competition, and I personally prefer the description by Bernard Baruch in which he points out that you do not have "to blow the other guy's light out in order for yours to shine." I think that this fits with the notion of members of a profession collaborating while still competing.
Finally, we have to be willing to train our competition. As Justice Brandeis noted [10], we have a responsibility to pass on a body of knowledge to the next generation. We must reverse this trend of falling applications for cardiothoracic surgery training. American society could make a major contribution by recognizing the opportunity costs involved in cardiothoracic training and to provide debt relief for those wishing to enter extended medical or surgical training after medical school. We should not force career choices to be made based on the need to pay off educational debt. Other education initiatives are being developed with our colleagues from the American Board of Thoracic Surgery, the Thoracic Surgery Directors Association, and the American Association for Thoracic Surgery that we hope will make cardiothoracic surgery more attractive as well.
If we are to fulfill our responsibilities as both healers and members of a profession, we must remember that we are truly balancing several responsibilities: responsibilities to our patients first, responsibilities to the society in which we live, and at some level, responsibilities to ourselves and to our families.
As I mentioned earlier, the health care cost issue moved off the political front burner for several years in the middle to late 1990s, but we now hear that health care will be the number one or number two domestic issue in this year's public policy agenda. My hypothesis is that when the annual growth rate of per capita health care expenditures exceeds the annual growth rate for the nation's gross domestic product, those times are when health care has been on the front burner of the national political agenda. These were the conditions in the early 1990s, and they have occurred again in the last few years. Now that the predicted economic downturn actually has occurred here in the United States, we will have that same phenomenon this year just as in 1993.
Now is the time to start influencing the development of health care reform. Recall that when President Bill Clinton and former presidential candidate Hillary Clinton were developing their health care policy in 1993 and 1994 and 400 or 500 health policy experts were working on various facets of this proposal, almost no physicians were involved. It seems to me that they did not think it was important that their policy include an appeal to the ideals and responsibilities of the medical profession to help solve health care's problems. I guess it was assumed that the doctors would just keep fulfilling their healing role and should not worry about health care policy. I personally think that approach was remarkably short-sighted.
I am fond of saying that the doctor's pen—or maybe nowadays it is the keyboard—still controls 75% of the health care expenditures in this country. I would argue that we do have a responsibility to society, as part of our profession's social contract, to help solve the problems of escalating costs in health care. We understand firsthand how the system works or does not work. We cannot be left out, as we were during the last effort at systematic health care reform in the early 1990s.
What can each of us do?
I hope I have convinced you that it is part of our professional responsibility to be involved in this political process of health care policy development, and I hope I have convinced you that being a member of a professional group like the STS is critically important. If we think about health care policy questions from the perspective of being a member of a profession, the case I have been trying to make today, some conclusions logically follow:
I would ask you to remember the words of Benjamin Franklin at the signing of the Declaration of Independence in 1776. "We must all hang together, or we shall surely all hang separately." By hanging together and remembering our common bond as members of our profession, we can withstand the external challenges to the practice of cardiothoracic surgery and begin to regain much of what it is we have lost. It will take a collective effort by all of us, each in his or her own way, but together, as members of a profession, we can do this.
In closing, I wish to thank all of the members of the STS leadership and professional staff who have helped me fulfill my responsibilities to the Society this year as your president. I also wish to recognize my surgical mentors, including Graeme Hammond, Edward Humphrey, Richard Varco, Robert Anderson, and Aldo Castaneda, and to particularly recognize Jack Matloff, former STS president, whose personal counsel has been so valuable to me over the years that I have been involved with the STS. More importantly, his foresight in setting up the health policy experience at the Kennedy School of Government was of great benefit to me and to all of cardiothoracic surgery. This course opened many of our minds to health policy issues and to the important responsibilities we have to American society beyond the operating room and the intensive care unit.
I also wish to express my appreciation to my partners in the Department of Cardiac Surgery at Children's Hospital, Boston, Pedro del Nido, Emile Bacha, Frank Pigula, Francis Fynn-Thompson, and Sitaram Emani, who have been extraordinarily gracious and generous with their time and support during this year.
Most importantly, I want to express my deepest appreciation to my family, who have been tolerant of my many absences and who have provided me with so much love and support. In particular, I wish to express my gratitude to my wife Christine, who for the last 37 years has been my toughest critic and greatest supporter. Her love and friendship have sustained me through some difficult times, and she was the essential parental presence for our children many times when I could not be there. Thank you also to our children for your love and understanding, and for never complaining about your father's absences over the years.
Finally, I wish to thank you, the membership of the STS, for giving me the opportunity to serve you over the last year. It has been a singular honor for me to serve you and our specialty.
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