The American College of Surgeons (ACS) has risen to the challenges associated with the pandemic and has sought to keep surgeons and other members of the surgical patient care team educated about postponement of nonurgent procedures, scaling back up during a decline in COVID-19 hospital admissions, and where we are headed in the aftermath of this crisis.
The indelible images of George Floyd’s killing in May 2020 served as another important wake-up call for many people and led the College to reconsider how we address issues of race, diversity, and inclusion. In response, an ACS task force has reviewed where the College has been and presently stands on racial issues and what more we can do to ensure surgical patients of all backgrounds and demographics receive high-quality care.
Medicare reimbursement cuts have been an ongoing threat to surgeons’ ability to maintain their practices for many years. This past year, the risk to surgeons, particularly individuals in private practice, was magnified by the COVID-19 shutdowns and a proposed rule from the Centers for Medicare & Medicaid Services (CMS) that would have resulted in pay cuts of up to 9 percent for some surgical specialties.
In this column, I briefly summarize the College’s initiatives related to all of these challenges and how we intend to move forward in 2021. Details regarding many of these efforts are provided throughout this issue of the Bulletin and in the Executive Director’s report posted here.
COVID-19: The game changer of our lifetime
The staff and volunteers of the ACS were quick to recognize COVID-19 as a public health crisis that required immediate action. We issued guidance on postponing nonurgent operations and quickly developed twice-weekly conference calls and mobilized our leaders to ensure that ACS members had guidance on how to manage the crisis.
Many of these directives were first published in a twice-weekly e-newsletter—Bulletin: ACS COVID-19 Updates—and we developed a web page devoted to COVID-19 resources.
In addition to changing how we communicate, COVID-19 presented the challenge of revisiting the format of our educational programming. Unfortunately, we had to cancel the Leadership & Advocacy Summit in 2020, but we were able to switch to a virtual format for three major conferences—the Quality and Safety Conference in August, the Clinical Congress in October, and the Trauma Quality Improvement Program in December.
Although this format does not satisfy two key elements of live meetings—the opportunity to meet with colleagues face-to-face and to engage in hands-on learning experiences—it did make the College’s programs more accessible to surgical professionals around the world. The ACS leadership agreed to make these virtual conferences available free of charge to all registrants in response to the financial hardships that many surgeons experienced because of the pandemic. Virtual Clinical Congress 2020 participants were able to earn more than 220 Continuing Medical Education credits without the expense of paying registration fees or associated travel costs. It was our gift to all surgeons, residents, medical students, and allied providers dealing with so many stressors throughout the year.
Going “color bold”
Another scourge that we confronted in 2020 was systemic racism. Without question, racism has always been an issue in the U.S. and around the world, but Mr. Floyd’s death, and the high-profile killing of other African Americans in recent years, shone a spotlight on the systemic racism that exists in our nation.
Soon after Mr. Floyd’s death, the ACS Board of Regents issued a call to action for all members of the ACS to proactively respond to racism in surgical care. But the ACS leadership agreed that a statement was an insufficient response. We quickly appointed an ACS Task Force on Racial Issues to take a hard look at how systemic racism affects patient care, surgical education, and opportunities for underrepresented minorities to achieve leadership positions in our profession.
Many of the articles in this issue of the Bulletin are by members of the Resident and Associate Society of the ACS, which chose Diversity, Equity, and Inclusion as the theme of its annual special issue. We also are publishing the ACS Task Force on Racial Issues’ recommendations, and ACS President J. Wayne Meredith, MD, FACS, MCCM, describes the workgroup’s activities in his Presidential Address. A regental committee, chaired by Timothy J. Eberlein, MD, FACS, has been appointed to implement the task force’s recommendations.
In addition, many College staff members serve on an internal task force that is developing recommendations to address racial issues in our Chicago, IL, and Washington, DC, offices. The College is working to establish an Office of Diversity, which will be responsible for administering the plan of action and for responding to staff concerns about inequities in the workplace.
Payment for surgical services
The ACS Practice Protection Committee and Division of Advocacy and Health Policy (DAHP) fought for legislative and regulatory relief for surgical practices experiencing financial hardships because of the pandemic, including incentives to expand the use of telehealth visits and the provision of small business loans. The committee and the DAHP issued guidance on these initiatives and led a series of webinars on related issues.
Then on August 3, 2020, the Centers for Medicare & Medicaid Services (CMS) released the proposed rule on the 2021 Medicare Physician Fee Schedule (MPFS). Under the proposal, surgeons would see their Medicare payments cut by 9 percent for cardiac surgery, 8 percent for thoracic surgery, 7 percent for vascular surgery, 7 percent for general surgery, 7 percent for neurosurgery, and 6 percent for ophthalmology. In addition, the conversion factor used in the Medicare payment methodology would drop from $36.09 to $32.26—the lowest amount in more than 25 years.
More specifically, beginning in 2021, CMS would eliminate the history and physical exam as elements for evaluation and management (E/M) code selection and would instead allow physicians to choose the E/M visit level based on the extent of their medical decision making or on time spent on the day of the encounter. CMS would increase the value of most office, outpatient, and E/M services, but these increases would not apply to global surgery codes.
To offset the increase in payment for E/M, CMS had to cut reimbursement for other services to maintain budget neutrality. The ACS repeatedly has expressed its opposition to CMS’ failure to increase payment rates for the E/M portion of 10- and 90-day global surgical packages and to any cuts in reimbursement, given the additional financial hardships surgeons have faced during the pandemic.
The College used several strategies to challenge the proposed cuts. First, we formed the Surgical Care Coalition. This group, which comprises 11 other surgical societies, represents more than 150,000 surgeons of all specialties.
The ACS and other Surgical Care Coalition member organizations led a successful campaign to encourage Congress to take legislative action that would eliminate the requirement for budget neutrality. As a result, Reps. Ami Bera, MD (D-CA); Larry Bucshon, MD, FACS (R-IN); Brendan Boyle (D-PA); George Holding (R-NC); Raul Ruiz, MD (D-CA); Roger Marshall, MD (R-KS); Abby Finkenauer (D-IA); Brad Wenstrup, DPM (R-OH); and 221 colleagues, sent a letter on October 19, 2020, to Speaker of the House Nancy Pelosi (D-CA) and House Minority Leader Kevin McCarthy (R-CA) urging them to protect patients by stopping the planned Medicare cuts.
In addition, the DAHP worked with ACS Fellows and members to facilitate contact with their representatives through SurgeonsVoice, and surgeons sent thousands of letters to members of Congress telling them to oppose Medicare payment cuts. In late December the Consolidated Appropriations Act of 2021 was enacted. Among many other things, this legislation mitigates major budget neutrality cuts to Medicare physician payments for CY 2021—a significant win for surgeons.
Other key activities
In addition to the major initiatives outlined previously, the College carried out the following activities in 2020:
- Developed a digital-forward strategy for communicating with ACS Fellows and other members, which includes rebuilding the College’s website, the addition of more video-based interviews to ACS publications; and an expanded social media presence.
- Welcomed 2,120 ACS Initiates at Convocation, 1,357 of whom are from the U.S. and Canada; 763 from 75 countries from around the world; and 585 women.
- Examined new horizons in surgical education and training through the ACS Academy of Master Surgeon Educators. The Academy has been working to identify major challenges facing surgery residency programs, faculty, and residents; define opportunities to address these challenges; design innovative residency training models; share resources, provide guidance, and disseminate novel educational methods and tools; and address key issues relating to governance of residency training programs through collaboration with national regulatory organizations.
- Released Surgical Education and Self-Assessment Program 17 Advanced, which features in-depth content for surgeons seeking further knowledge in specific areas, including abdomen and alimentary tract, breast, endocrine, surgical critical care, and trauma surgery.
- Building on the work of the Firearm Strategy Team (FAST) Work Group, the Committee on Trauma created ISAVE: Improving Social determinants to Attenuate ViolencE—a multidisciplinary group of health care providers and community advocates who have knowledge and experience in chronic conditions and understand how these diseases intersect with inequity and health care disparities.
- After last year’s launch of a new public-facing website, STOP THE BLEED® experienced exponential growth globally, with the program being offered in more than 120 countries as the premier bleeding control program.
- Developed the ACS Quality Verification Program (ACS QVP), which sets standards of care based on the foundational elements set forth in the ACS Red Book (Optimal Resources for Surgical Quality and Safety).
- Began pilot testing a program to verify rural hospitals.
- Successfully moved site visits for all ACS accreditation and verification programs to a virtual platform to ensure the safety of site reviewers and hospital patients and personnel.
Looking forward
The challenges we experienced in 2020 were unprecedented. However, we have learned many valuable lessons along the way. This new knowledge will allow us to better manage future public health crises, to contribute to a more just and inclusive health care system, and to continuously develop innovative approaches to educating and informing our members. With your continued involvement and input, I truly believe better days are coming.
Thank you for all you do, and happy New Year.
