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Health care quality, access, cost, workforce, and surgical education: the ultimate perfect storm
Journal of Pediatric Surgery (2012) 47, 1–9
www.elsevier.com/locate/jpedsurg
Presidential address
Health care quality, access, cost, workforce, and surgical education: the ultimate perfect storm Marshall Z. Schwartz ⁎ Surgery and Pediatrics, Drexel University College of Medicine, Temple University School of Medicine, Philadelphia, PA 19134, USA Pediatric Surgery, St. Christopher's Hospital for Children, Philadelphia, PA 19134, USA Received 24 September 2011; accepted 6 October 2011
Key words: Health care; Quality; Safety; Workforce; Access; Cost
Abstract The discussions on health care reform over the past two years have focused on cost containment while trying to maintain quality of care. Focusing on just cost and quality unfortunately does not address other very important factors that impact on our health care delivery system. Availability of a well-trained workforce, maintaining the sophisticated medical/surgical education system, and ultimately access to quality care by the public are critical to maintaining and enhancing our health care delivery system. Unfortunately, all five of these components are under at risk. Thus, we have evolving the ultimate perfect storm affecting our health care delivery system. Although not ideal and given the uniqueness of our population and their expectations, our current delivery system is excellent compared to other countries. However, the cost of our current system is rising at an alarming rate. Currently, health care consumes 17% of our gross domestic product. If our system is not revised this will continue to rise and by 2025 it will consume 48%. The dilemma, given the current state of our overall economy and rising debt, is how to address this major problem. Unfortunately, the Affordable Care Act, which is now law, does not address most of the issues and the cost was initially grossly under estimated. Furthermore, the law does not address the issues of workforce, maintaining our medical education system or ultimately, access. A major revision of our system will be necessary to truly create a system that protects and enhances all five of the components of our health care delivery system. To effectively accomplish this will require addressing those issues that lead to wasteful spending and diversion of our health care dollars to profit instead of care. Improved and efficient delivery systems that reduce complications, reduction of duplication of tertiary and quaternary programs or services within the same markets (i.e. regionalization of care), health insurance reform, and tort reform collectively could save hundreds of billion dollars per year! These changes may not be easy to accomplish politically but will be essential to save what is likely the best health care system in the world. © 2012 Published by Elsevier Inc.
⁎ Corresponding author. Tel.: +1 215 427 5446. E-mail address: [email protected]. 0022-3468/$ – see front matter © 2012 Published by Elsevier Inc. doi:10.1016/j.jpedsurg.2011.10.011
2
We all remember this phrase: “Houston, we have a problem.” This referred to Apollo 13 in April 1970. America, we have a problem! However, it is not our economy that I am referring to, but it is the components of our health care delivery system which are under siege. Health care quality, safety, and access have always been a major concern of Americans, and these issues escalated during the recent health care debates. In contrast, the discussion emanating from our Federal Government has focused on cost containment. What has been absent is a full discussion on the other important aspects of health care delivery, such as excellent medical/surgical education and providing a well-trained, competent, and sufficient workforce which has made our system the best in the world. The reality is that to optimize our health care delivery system requires that we must address all of these factors. Because all of these factors are under attack, we are facing the “ultimate perfect storm.” Focusing this presentation on health care quality, access, cost, workforce, and surgical education in the timeframe allotted is difficult. However, I chose this topic because of my strong interest and recent involvement in health care policy, knowing full well that the scope is broad, and it could consume many hours to fully discuss. Regardless, the important message is that these five components of our health care delivery system overlap, and thus, define what makes our system unique. The ultimate outcome of health care delivery in this country will have to involve all of these components, but the difficulty is that in the current political environment, they have become in conflict with each other. I was not the first person to talk about health care in an American Pediatric Surgical Association (APSA) presidential address. The first was Dr Hardy Hendren in 1983. He titled his presentation: “Some Reflections on the Cost of Health care” where he pointed out that the rising cost of health care was not from physician or surgeon fees but from changes in lifestyles and the fact that America was becoming an unhealthy society [1]. Note the foresight of Dr Hendren in talking about this issue 30 years ago! In 1992, Dr Al de Lorimier's presidential address entitled: “Health care Costs in a Declining America,” looked at the changes occurring in America as it relates to the tolerance of lifestyles and the relationship of those lifestyles to the added cost of health care [2]. Subsequently in 1995, Dr Jay Grosfeld in his presidential address entitled: “Economics and Education: Impact on Pediatric Surgery in the Next Decade” provided a wonderful, comprehensive discussion on the
M.Z. Schwartz impact of the rising cost of health care and the source of the dollars for health care on medical education overall, and particularly as it relates to surgery and pediatric surgery [3]. Unfortunately, many of these issues that Dr Grosfeld addressed, as well as Dr de Lorimier and Hendren, still exist, and in fact, most of them are worse. A year ago our country went through extensive debate over a bill that ultimately became law as the “Affordable Care Act.” Unfortunately, much of what was defined in the Affordable Care Act was predetermined as a result of negotiations between the Executive Branch of our Government and the major players (the health insurance industry, hospital associations, pharmaceutical industry, and the trial lawyers) that define or greatly influence our health care delivery system. The reality is that the major aspects of this legislation were worked out well before it became a public debate. There were commitments politically made by the American Hospital Association, “Big Pharma,” the health insurance industry, and the Trial Lawyers Association. Each group made a commitment to save billions of dollars in cost reduction, if their specific priorities would be protected. Thus, the bill was really not an open debate. Remarkably, the evolution of this bill (now law) did not involve the providers of health care! That is, those of us present here today, i.e. doctors, nurses, etc. As health care providers, all of us care about the quality of our health care delivery system, but many difficult questions linger, such as: will there be an adequate workforce available to provide it? Will we have well-trained medical professionals in our medical/surgical education system? Will the ultimate cost of that care be affordable? Finally, will there be access to quality care that meets the expectations of the American public?
1. Quality The definition of “quality health care” depends on who you ask and what country you are in. However, as health care providers we inherently know what we mean and we strive to deliver it. As pediatric surgeons we strive to do the best for our patients. We also know that quality of care is not just what we do, but it is also dependent on the resources and competence of the environment in which we work. You might be thinking that we do not have much control over our collective work environment, but in fact we do, and history bears this out. The advances in health care and health care delivery in America have been dramatic. People are living longer and with a better quality of life. The components that impact on quality health care in the United States are different from every other country. Whatever works or is deemed acceptable in another country may not be applicable or acceptable with the American public. We have 310 million people, and a tremendous diversity in culture, socioeconomic status, geography, and governance. However, we have created a culture of high
Health care quality, access, cost expectations, which is a big factor in defining the difference between the United States and other countries. Clearly, “one size does not fit all” when you are defining health care quality. Despite its shortcomings, in my view America still has the best health care delivery system, medical education system, nursing and physician extender education system, medical innovation system (eg, pharmaceuticals, devices, imaging, etc.), and the best basic science medical discovery system. We are the idol of the rest of the world in terms of discovery and medical innovation, but yes, we do have problems. There is a significant impact on cost to develop this innovation, and the benefits result in people living longer and thus needing to access our health system. The public understands that quality health care is critically important to them and their families. There is also a tendency by the public to take quality health care for granted regardless of their resources. Whether we agree that health care is a right or a privilege, or whether the quality of care is uniform, the fact is that in the United States, more so than any other country, if you need it—you can get it. However, inherent in this equation is personal or parent responsibility! The health care bill debate clearly energized the public, but they did not necessarily understand what was being debated or what the ultimate outcome of that debate was going to be. However, there was this sense that the changes “did not feel right.”
2. Cost The cost of delivering health care in the United States is the highest per capita in the developed countries, and we can not continue on this trajectory. For example Medicare and Medicaid have significantly increased the consumer price index. When you listen to the political wonks in Washington, they do not talk about cost in dollars. They talk about “bending the cost curve.” Dr Hendren in his 1983 presidential address lamented that the cost of health care was 10% of the gross domestic product (GDP) of the United States [1]. We would be thrilled if that was the case today. During the timeframe of 1960-2005, the percentage of GDP contributable to health care costs rose from 4% to 15% [4]. From 2007 to 2082, it will rise from 16% to 98%! Currently, health care costs account for ∼17% of our GDP. By 2025, it will be 28%, and by 2050, it will be ∼48% [4]. Clearly, this is not sustainable! Furthermore, if you add our $14 trillion debt to this trajectory, the combination will significantly accelerate the consumption of our total GDP [4]. The irony of this scenario is that there is more than enough money to fund health care for the American people, but our current structure is wrong. Who and what controls and has access to the money in our system is our problem. We need to address this question, but how? What are the options? The Federal Government over the past 40 years attempted to control rising health care costs but were
3 unsuccessful. A few decades ago, the private sector, (ie, the private health insurance industry) was invited to help. Thus, the birth of managed care. Over the past 20 years, the health insurance industry has been successful in reducing payments to hospitals and physicians through a multitude of maneuvers. However, much of the savings were never put back into the health care delivery system but were retained as profits by the insurance industry. Thus, it did not exactly turn out as planned. There are many reasons why the cost of health care has continued to escalate. Some reasons are legitimate (new technology, rising overhead, etc), and some reasons are not (defensive medicine, medical liability insurance premiums, siphoning of dollars out of the system as profits, mismanagement, etc). The economics of our health care delivery system is presumed to be based on capitalism, but in practice, it is not. Capitalism in its purest sense (supply and demand) does not really describe our system because there are “third parties” such as the health insurers and federal and state agencies that have a major influence or control of the health care dollars. Another significant factor which is attributable to the providers is excessive duplication of tertiary and quaternary care in the same community. Hospital-based programs such as organ transplantation, joint replacement, and cardiac surgery are profitable for the hospitals, so there is over duplication of these programs in many metropolitan centers. This aspect of “capitalism” has a negative impact on health care delivery by significantly increasing cost (by duplication of equipment, personnel, and perpetual advertising) and decreasing quality (by creating smaller programs and diffusing the specialty workforce). I practice in a metropolitan area where we have 7 transplant programs within 10 miles of each other. We have four university hospitals and several large community hospitals with tertiary/quaternary programs all competing with each other. That excessive duplication of care costs a lot of money, which could be better spent if there was some form of centralization that would more closely balance need with access,. I am definitely not implying socialized medicine, just cost reduction by adjusting services to the demographics. On a national level this would be a cost savings in the billions of dollars which could be funneled back into the health care delivery system. As mentioned earlier, the public has expectations that when they want or need health care, they should have it, whether they have any resources to pay for it or not. The issue here is not whether health care is a right or a responsibility. The reality is that it is an expectation in our culture. There is really nothing wrong with that expectation as long as it is moderated, and we can somehow pay for it.
3. Workforce The public is not informed nor do they understand that there is an overall physician workforce shortage. Furthermore,
4
M.Z. Schwartz
1,000,000 800,000 600,000
297.4
Physicians Per 100,000 Population Population is U.S. civilian population including possessions
142.2
141.6
277.4
299.2 988,100
906,278
236.9 776,301
195.9 601,237
155.6 453,165
400,000
323,799 219,897
259,443
200,000 0 1950
1960
1970
1980
1990
2000
2010
2020
Source: Bureau of Health Professions
Fig. 1 Supply of active physicians (MD and DO) and ratio to the population: actual 1950-1990 and projected 2000-2020. Note the flattening of growth beginning in 2000. Data compiled from the Bureau of Health Professions.
the public can not easily comprehend the impact of a physician shortage, especially in many of the medical and surgical specialties. I believe that this may be the tipping point for the public when access becomes a major issue for children's care. More importantly, of relevance to us is that the shortage will be greatest in the pediatric and pediatric surgical specialties. Because the public does not understand or are engaged in this issue, our elected officials, mostly at the federal level, are really not willing to get engaged in the discussion. Because workforce issues are not on the public's mind, and they are not demanding solutions, it is not going to be a priority for Congress or the President. Why? Because it is not yet a basis for determining the public's vote and thus, determining their re-election. Their primary responsibility if they want to stay in office, is to respond to their constituents, and if this is not on the radar screen of their constituents, it is not going to be their priority. We train a lot of doctors in the United States, and we also recruit them from other countries. Fig. 1 shows the increase in physicians starting from 1950 to what is projected to 2020. There is a leveling off between 2010 and 2020. This is concerning because our population is not equally distributed by age. We have this large influx of “baby boomers” that are 80 million strong and entering the age at which a large percentage will require health care. What has been able to compensate for the workforce shortfall so far is the significant increase in physician assistants and nurse practitioners (Fig. 2). Physician extenders can handle a moderate amount of what a primary care physician does, but they are limited when it comes to enhancing the surgery workforce. They can help us in the operating room, but they cannot operate. However, it was the Academy of Family Physicians who lobbied Congress about the shortage of primary care physicians that received all of the attention in Washington, DC. Serious attention by Congress regarding the impending workforce shortage is unlikely to occur because the funding for resident training comes from Medicare, and there has
been a moratorium on all new resident positions since 1997. An even bigger issue facing General Surgery is the fact that there has been a dramatic progression by surgery residents to elect fellowship training, which is now estimated to be ≥80%! This is a major problem because we still need general surgeons in community hospitals, rural hospitals, and to provide care that specialists may no longer have in their skill set. In fact, this is already a major concern for finishing residents in General Surgery that completed a fellowship. Within a short period of time they are telling their community hospital administrations and medical staffs that they do not feel qualified anymore to take general surgery call for the emergency department. Thus, this will create a real access to care problem in this country in the near future. Another issue is the General Surgery aging workforce. Thirty-five percent of the surgical workforce is over 55 years of age. By 2014 that number is predicted to jump to 42 percent. Thus, a large group of surgical practitioners are going to retire soon, and we will not have sufficient backfill to accommodate the demand. Shown in Fig. 3 is the distribution of general surgeons in the United States. The largest blue circles indicate the greatest number of general surgeons per capita. They are concentrated in the major population areas mostly in the Northeast, likely because of the large number of training programs in teaching hospitals in the Northeast corridor and also other regions such as Southern California. The Pediatric Surgery workforce is and will become an even greater access problem in the future. There are currently approximately 780 to 800 practicing pediatric surgeons in the United States (Fig. 4). It is estimated that there are approximately 80-100 open positions in Pediatric Surgery in the United States at the present time. Thus, the supply clearly does not meet the demand. Currently, recruitment of a pediatric surgeon has become very challenging. The number
Cumulative growth since 1990 % rate of growth (cumulative) since 1990
Supply (Thousands)
Supply of Active Physicians (MD & DO) and Ratio to Population Actual 1950-1990 and Projected 2000-2020
250 Nurse Practitioners 247%
200
150
Physician
Assistants 152%
100
50 Physicians 32.2%
0
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002
Year
Fig. 2 Cumulative growth of physicians, physicians assistants, and nurse practitioners. Note the significant growth in physicians assistants and nurse practitioners in contrast to physicians. Data compiled from the Bureau of Health Professions.
Health care quality, access, cost
Distribution of surgeons by county in 2006. Note the high concentration in the northeast and southern California.
of training programs in Pediatric Surgery has gradually increased over time. Recently, there have been more applications for new Pediatric Surgery fellowships. However, it still does not meet the demand. At present there are 41 Accreditation Council for Graduate Medical Education (ACGME)–approved training programs in Pediatric Surgery in the US and 6 programs in Canada. Some of the programs in the United States are limited to one trainee every other year. Approval of new programs is based on an application to the Surgery RRC that successfully meets the ACGME defined program requirements. There has been a long standing misconception that the field of Pediatric Surgery can control the number of training slots. This is not correct. The fact is that if a program applies and meets the ACGME criteria, the program must be approved. The other misconception is that the criteria are so demanding that relatively few programs qualify. This is also not the case. Thus, the Surgery Residency Review Committee (RRC) decision about approval of training programs, whether it is Pediatric Surgery, General Surgery, or Vascular Surgery, is based on the defined educational criteria. It can not be based on need or economics. In fact, this would be restraint of trade, which is a federal felony. Fig. 4 illustrates data from the American College of Surgeons (ACS) Health Policy Research Institute on the
number of pediatric surgical specialists from 1981 to 2006. When I first saw this data, I was alarmed, not so much with the Pediatric Surgery numbers but the very low numbers of
Pediatric Surgical Supply, 1981 - 2006 Number of Pediatric Surgeons
Fig. 3
5
800 700 600 500 400 300 200 100 1981
1986
Pediatric Surgery Pediatric Urology
1991
1996
Pediatric Orthopedics Pediatric Neurological Surgery
2001
2006
Pediatric Ophthalmology Pediatric Otolaryngology
Pediatric Cardiothoracic Surgery
Source: AMA Physician Masterfile data, 1981 – 2006. Produced by the American College of Surgeons Health Policy Research Institute.
Fig. 4 Number of pediatric general surgeons and pediatric surgical specialists by specialty from 1981 to 2006. The data from 1981 to 1991 includes all pediatric surgeons combined because the data was lacking on specific specialties. The data from 1996 to 2006 represent data for all specialties. Note how few pediatric surgical practitioners there are in 2006.
6 the pediatric surgery subspecialists. I frequently mention Pediatric Neurosurgery for two reasons: (1) Currently, there are only approximately 130 practicing pediatric neurosurgeons in the United States with an average age of 55 years old, and (2) there are only 10 training programs in Pediatric Neurosurgery in the United States. However, in the last few years, no more than 50% of these training slots have filled! With only approximately 5 trainees in Pediatric Neurosurgery per year, and with half of the workforce 55 years old or older now, there is looming a major access to care problem. Whereas there is crossover in skills and training in some surgical specialties, who is the crossover or backfill for a pediatric neurosurgeon? Who can treat a newborn with hydrocephalus or a 2-year old with a brain tumor besides a pediatric neurosurgeon? This is a major unaddressed concern, but it is not unique to Pediatric Neurosurgery. There are many pediatric and pediatric surgical specialties facing significant workforce shortages including pediatric general surgery. Where are we going to be in 10 years? Fig. 5 is a map showing the distribution of pediatric surgeons, both general pediatric surgeons, and pediatric surgical specialists, in the United States as of 2006. Similar to the general surgery
M.Z. Schwartz map, you have the same concentrated areas where pediatric surgeons are located. Note that parts of the Midwest and Northwest are poorly covered by pediatric surgeons. That is concerning because of the travel distance necessary to find a pediatric surgeon. This could create a life or death situation and probably does. To summarize, we have a looming workforce shortage which will be more of an issue in the specialty areas then primary care because of the lack of crossover or backfill for the pediatric surgery providers.
4. Surgical education Another factor that contributes to our health care delivery system is surgical education, and it is also under attack. From the vantage point of Congress and the President, GME is an easy target because the funding comes from Medicare, and reduction in funding would not be initially understood to impact the public. Furthermore, the academic world probably does not have the financial or political clout to prevent it from happening. The major academic oversight
Fig. 5 Number of pediatric general surgeons and pediatric surgical specialists by county in 2006. Note the significant concentration in the northeast and southern California.
Health care quality, access, cost in America includes the Association of American Medical Colleges (AAMC); American Board of Medical Specialties (ABMS) ,which includes the American Board of Surgery; and the ACGME, which includes the Surgery Residency Review Committee (RRC). I believe there is confusion and misunderstanding about these organizations and how they arose and where their authority comes from. The AAMC is a private, nonprofit organization which started in 1876 and initially represented 22 medical schools. Today, the AAMC represents all 135 accredited US and 17 accredited Canadian medical schools; approximately 400 major teaching hospitals and health systems, including 62 Department of Veterans Affairs medical centers; and nearly 90 academic and scientific societies. Through these institutions and organizations, the AAMC represents 125,000 faculty members, 75,000 medical students, and 106,000 resident physicians. The ACGME is a private, nonprofit council. It is not a government agency, and although the government certainly has some influence over medical education, it does not directly control the ACGME. The mission of the ACGME is to define medical specialty training program educational criteria and evaluate and accredit residency training programs in the United States. It was established in 1981. Thus, it is not as long standing as long as one would think. There are currently 8,734 ACGME accredited residency programs involving 130 specialties and subspecialties. Under the ACGME umbrella, there are 28 review committees, 26 of which are focused on medical or surgical specialties. Under the umbrella of the Surgery RRC are General Surgery, Vascular Surgery, Surgical Critical Care, and Pediatric Surgery. The RRC has some mobility in setting standards for their respective specialty areas, but the overarching educational goals are defined by the ACGME structure. The ABMS is also a private, nonprofit organization that dates back to 1933. Under the ABMS umbrella, there are 24 medical and surgical specialty boards, and their primary roles are to evaluate and certify trainees as competent in the field for which they have trained and to define the criteria to recertify practitioners in those specialties. Thus, the AAMC helps to define medical school education, the ACGME accredits training programs, and the ABMS certifies trainees and recertifies practitioners. It should be noted again that all three of these organizations are private and not directly governed by Congress or the Executive Branch. However, the influence of the government is not without significance, specifically as it relates to funding, work hours, etc., through congressional mandates or Institute of Medicine recommendations. The impact of funding for graduate medical education by the Federal government is significant. In 1969, when the Medicare Act was passed, it included funding provisions for GME. This really opened the door for expansion of training programs and trainees in hospitals. Currently, each accredited training program receives approximately $100,000 per trainee per year. A major university Medical Center with
7 several accredited training programs will receive millions of dollars. Overall, the Government funding for GME is around $9.5 billion a year. A substantial reduction in these funds would have a major negative impact on the number of residents being trained, resident education, as well as a significant impact on hospital budgets. What has added to this dilemma is the Balanced Budget Act of 1997, which instituted a moratorium on funding for new GME slots. Thus, there has been no new funded GME positions since 1997. That is why you see the growth curves in workforce flattening out and will become completely flat. Some of the hospitals are willing to pay for residency training out of their own resources which have produced a slight increase in some specialties. Our Government began to recognize, to some extent, the workforce issue and encouraged medical schools to expand their enrollment and start new medical schools. However, with no increase in funded resident training positions we are going to have a lot of medical students that will not get a residency, at least not in their specialty choice.
5. Access Finally, what about access to care? This is really the critical issue as far as the public is concerned. With all of the negative impacts on quality, workforce, education, and cost reduction, under current circumstances, it will be impossible
Fig. 6
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M.Z. Schwartz
Fig. 7
to avoid a significant negative impact on patient access. This is when the public will finally get involved in this impending crisis. Unfortunately, the damage will be done, and recovery will be difficult. The beginning of this is already occurring. We see it in our own emergency rooms and in long wait times to get appointments with certain specialists. It is good now compared to where we are headed in 5-10 years. This will be the timeframe when the public will realize what has happened and the level of agitation, frustration, and anger will increase.
Fig. 8
Fig. 9
Thus, optimum health care delivery in America really is under attack. So what can we do? As providers of pediatric surgical care, do we just have to let this happen? That would not be consistent with our profession. The surgical specialties need to avoid the usual “soapbox” demands of increased reimbursement and malpractice reform. Unfortunately, this is how surgeons are viewed in Washington, and we have little sensitivity or support from the public regarding either of these issues. The other major issue is the fragmentation of the surgical specialties. Because we have not been successful in
Fig. 10
Health care quality, access, cost reaching sufficient common ground among the major surgical specialties, we have successfully divided and conquered ourselves! We do not have an effective collective voice in Washington or even within our own state governments. During the past several decades, we have witnessed the health insurance industry gain control of the private sector health care dollars and at the same time reduce reimbursement to hospitals and to a greater extent to physicians and surgeons. In addition, we have seen the medical liability costs increase and the pharmaceutical industry also has an increasing role in the economics of health care. Thus, we are outspent and outmaneuvered by these industries. The American Medical Association (AMA), as the spokes-entity for medicine, used to have clout but for numerous reasons has also splintered within its ranks. The clout of the AMA in Washington right now has diminished substantially. We really need to create an effective and cohesive surgical coalition that can speak for the “House of Surgery,” and we need to develop strategies for Surgery to gain credibility with the public. Why? Because the public is our best ally. The public, once informed and supportive of our goals, will trump the health insurance industry, the hospital associations, big pharma, and the trial lawyers. Our best route for this success is to combine quality of care with cost reduction. The ACS has been pursuing these goals since its inception in 1913. The Joint Commission came out of efforts by the ACS. Advanced Trauma Life Support was started several decades ago, and the College played a significant role in the evolution of the Commission on Cancer. More recently, the ACS initiated the National Surgery Quality Improvement Program, which has been very successful in reducing surgical complications (and improving quality) in the member hospitals. The participating hospitals have shown a dramatic reduction in complications and therefore, health care costs. Another effort by the ACS has been to establish a Health Policy Research Institute (ACS-HPRI) to develop peer-reviewed health policy data related to surgical care. In addition, to improve the presence of the ACS and the “House of Surgery” in Washington, the College built a 10-story building that is walking distance to the Capitol. As surgeons, we have achieved a great deal of credibility. Unfortunately, we have not done a very good job in communicating it to our Government and the public. Through recent and on-going efforts, the ACS has begun a
9 campaign referred to as: “Inspiring Quality-Highest Standards, Better Outcomes.” In addition, the ACS has made an effort to bring together more than 20 surgical associations to define common goals regarding health care policy and, thus, to form a true coalition. Currently, this involves approximately 240,000 surgeons. If this coalition can solidify, it will create considerable visibility and clout in Washington. This is the path for the “House of Surgery” to gain the credibility and impact on the public and Congress that is required for us to influence the policies that will impact on us in the future. If we fail in these efforts, more federal policies will further compromise our ability to maintain the best health care delivery system. I have been extremely fortunate throughout my career and wish to acknowledge a few of the individuals that have mentored, supported, and facilitated my career: Henry Buchwald, a surgeon-scientist at the University of Minnesota, who accepted me into his laboratory and gave me my own basic science research project as a third year medical student in 1968 and has been a mentor and friend ever since (Fig. 6); John Najarian, who was the Chief of Surgery at the University of Minnesota during my general surgery residency, who was not only an excellent chairman but allowed me to bypass a senior year to do my chief year and begin pediatric surgery training in Boston one year earlier than planned (Fig. 7); Jim Thompson, Chief of Surgery at the University of Texas Medical Branch, another surgeon-scientist, who fostered my GI research career (Fig. 8); Judah Folkman, the ultimate surgeon-scientist and the most brilliant and inspiring person I have ever known, who taught me so many things by example including humanity and humility (Fig. 9); and David Tapper, who was an enormous inspiration to me, accomplished much in a very short time, and left us way too soon. He was my best friend (Fig. 10).
References [1] Hendren WH. Some reflections on the cost of health care. J Pediatr Surg 1983;18:659-69. [2] de Lorimier AA. Health care costs in a declining America. J Pediatr Surg 1993;28:281-91. [3] Grosfeld JL. Economics and education: impact on pediatric surgery in the next decade. J Pediatr Surg 1996;31:3-11. [4] Data from the Congressional Budget Office.
www.elsevier.com/locate/jpedsurg
Presidential address
Health care quality, access, cost, workforce, and surgical education: the ultimate perfect storm Marshall Z. Schwartz ⁎ Surgery and Pediatrics, Drexel University College of Medicine, Temple University School of Medicine, Philadelphia, PA 19134, USA Pediatric Surgery, St. Christopher's Hospital for Children, Philadelphia, PA 19134, USA Received 24 September 2011; accepted 6 October 2011
Key words: Health care; Quality; Safety; Workforce; Access; Cost
Abstract The discussions on health care reform over the past two years have focused on cost containment while trying to maintain quality of care. Focusing on just cost and quality unfortunately does not address other very important factors that impact on our health care delivery system. Availability of a well-trained workforce, maintaining the sophisticated medical/surgical education system, and ultimately access to quality care by the public are critical to maintaining and enhancing our health care delivery system. Unfortunately, all five of these components are under at risk. Thus, we have evolving the ultimate perfect storm affecting our health care delivery system. Although not ideal and given the uniqueness of our population and their expectations, our current delivery system is excellent compared to other countries. However, the cost of our current system is rising at an alarming rate. Currently, health care consumes 17% of our gross domestic product. If our system is not revised this will continue to rise and by 2025 it will consume 48%. The dilemma, given the current state of our overall economy and rising debt, is how to address this major problem. Unfortunately, the Affordable Care Act, which is now law, does not address most of the issues and the cost was initially grossly under estimated. Furthermore, the law does not address the issues of workforce, maintaining our medical education system or ultimately, access. A major revision of our system will be necessary to truly create a system that protects and enhances all five of the components of our health care delivery system. To effectively accomplish this will require addressing those issues that lead to wasteful spending and diversion of our health care dollars to profit instead of care. Improved and efficient delivery systems that reduce complications, reduction of duplication of tertiary and quaternary programs or services within the same markets (i.e. regionalization of care), health insurance reform, and tort reform collectively could save hundreds of billion dollars per year! These changes may not be easy to accomplish politically but will be essential to save what is likely the best health care system in the world. © 2012 Published by Elsevier Inc.
⁎ Corresponding author. Tel.: +1 215 427 5446. E-mail address: [email protected]. 0022-3468/$ – see front matter © 2012 Published by Elsevier Inc. doi:10.1016/j.jpedsurg.2011.10.011
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We all remember this phrase: “Houston, we have a problem.” This referred to Apollo 13 in April 1970. America, we have a problem! However, it is not our economy that I am referring to, but it is the components of our health care delivery system which are under siege. Health care quality, safety, and access have always been a major concern of Americans, and these issues escalated during the recent health care debates. In contrast, the discussion emanating from our Federal Government has focused on cost containment. What has been absent is a full discussion on the other important aspects of health care delivery, such as excellent medical/surgical education and providing a well-trained, competent, and sufficient workforce which has made our system the best in the world. The reality is that to optimize our health care delivery system requires that we must address all of these factors. Because all of these factors are under attack, we are facing the “ultimate perfect storm.” Focusing this presentation on health care quality, access, cost, workforce, and surgical education in the timeframe allotted is difficult. However, I chose this topic because of my strong interest and recent involvement in health care policy, knowing full well that the scope is broad, and it could consume many hours to fully discuss. Regardless, the important message is that these five components of our health care delivery system overlap, and thus, define what makes our system unique. The ultimate outcome of health care delivery in this country will have to involve all of these components, but the difficulty is that in the current political environment, they have become in conflict with each other. I was not the first person to talk about health care in an American Pediatric Surgical Association (APSA) presidential address. The first was Dr Hardy Hendren in 1983. He titled his presentation: “Some Reflections on the Cost of Health care” where he pointed out that the rising cost of health care was not from physician or surgeon fees but from changes in lifestyles and the fact that America was becoming an unhealthy society [1]. Note the foresight of Dr Hendren in talking about this issue 30 years ago! In 1992, Dr Al de Lorimier's presidential address entitled: “Health care Costs in a Declining America,” looked at the changes occurring in America as it relates to the tolerance of lifestyles and the relationship of those lifestyles to the added cost of health care [2]. Subsequently in 1995, Dr Jay Grosfeld in his presidential address entitled: “Economics and Education: Impact on Pediatric Surgery in the Next Decade” provided a wonderful, comprehensive discussion on the
M.Z. Schwartz impact of the rising cost of health care and the source of the dollars for health care on medical education overall, and particularly as it relates to surgery and pediatric surgery [3]. Unfortunately, many of these issues that Dr Grosfeld addressed, as well as Dr de Lorimier and Hendren, still exist, and in fact, most of them are worse. A year ago our country went through extensive debate over a bill that ultimately became law as the “Affordable Care Act.” Unfortunately, much of what was defined in the Affordable Care Act was predetermined as a result of negotiations between the Executive Branch of our Government and the major players (the health insurance industry, hospital associations, pharmaceutical industry, and the trial lawyers) that define or greatly influence our health care delivery system. The reality is that the major aspects of this legislation were worked out well before it became a public debate. There were commitments politically made by the American Hospital Association, “Big Pharma,” the health insurance industry, and the Trial Lawyers Association. Each group made a commitment to save billions of dollars in cost reduction, if their specific priorities would be protected. Thus, the bill was really not an open debate. Remarkably, the evolution of this bill (now law) did not involve the providers of health care! That is, those of us present here today, i.e. doctors, nurses, etc. As health care providers, all of us care about the quality of our health care delivery system, but many difficult questions linger, such as: will there be an adequate workforce available to provide it? Will we have well-trained medical professionals in our medical/surgical education system? Will the ultimate cost of that care be affordable? Finally, will there be access to quality care that meets the expectations of the American public?
1. Quality The definition of “quality health care” depends on who you ask and what country you are in. However, as health care providers we inherently know what we mean and we strive to deliver it. As pediatric surgeons we strive to do the best for our patients. We also know that quality of care is not just what we do, but it is also dependent on the resources and competence of the environment in which we work. You might be thinking that we do not have much control over our collective work environment, but in fact we do, and history bears this out. The advances in health care and health care delivery in America have been dramatic. People are living longer and with a better quality of life. The components that impact on quality health care in the United States are different from every other country. Whatever works or is deemed acceptable in another country may not be applicable or acceptable with the American public. We have 310 million people, and a tremendous diversity in culture, socioeconomic status, geography, and governance. However, we have created a culture of high
Health care quality, access, cost expectations, which is a big factor in defining the difference between the United States and other countries. Clearly, “one size does not fit all” when you are defining health care quality. Despite its shortcomings, in my view America still has the best health care delivery system, medical education system, nursing and physician extender education system, medical innovation system (eg, pharmaceuticals, devices, imaging, etc.), and the best basic science medical discovery system. We are the idol of the rest of the world in terms of discovery and medical innovation, but yes, we do have problems. There is a significant impact on cost to develop this innovation, and the benefits result in people living longer and thus needing to access our health system. The public understands that quality health care is critically important to them and their families. There is also a tendency by the public to take quality health care for granted regardless of their resources. Whether we agree that health care is a right or a privilege, or whether the quality of care is uniform, the fact is that in the United States, more so than any other country, if you need it—you can get it. However, inherent in this equation is personal or parent responsibility! The health care bill debate clearly energized the public, but they did not necessarily understand what was being debated or what the ultimate outcome of that debate was going to be. However, there was this sense that the changes “did not feel right.”
2. Cost The cost of delivering health care in the United States is the highest per capita in the developed countries, and we can not continue on this trajectory. For example Medicare and Medicaid have significantly increased the consumer price index. When you listen to the political wonks in Washington, they do not talk about cost in dollars. They talk about “bending the cost curve.” Dr Hendren in his 1983 presidential address lamented that the cost of health care was 10% of the gross domestic product (GDP) of the United States [1]. We would be thrilled if that was the case today. During the timeframe of 1960-2005, the percentage of GDP contributable to health care costs rose from 4% to 15% [4]. From 2007 to 2082, it will rise from 16% to 98%! Currently, health care costs account for ∼17% of our GDP. By 2025, it will be 28%, and by 2050, it will be ∼48% [4]. Clearly, this is not sustainable! Furthermore, if you add our $14 trillion debt to this trajectory, the combination will significantly accelerate the consumption of our total GDP [4]. The irony of this scenario is that there is more than enough money to fund health care for the American people, but our current structure is wrong. Who and what controls and has access to the money in our system is our problem. We need to address this question, but how? What are the options? The Federal Government over the past 40 years attempted to control rising health care costs but were
3 unsuccessful. A few decades ago, the private sector, (ie, the private health insurance industry) was invited to help. Thus, the birth of managed care. Over the past 20 years, the health insurance industry has been successful in reducing payments to hospitals and physicians through a multitude of maneuvers. However, much of the savings were never put back into the health care delivery system but were retained as profits by the insurance industry. Thus, it did not exactly turn out as planned. There are many reasons why the cost of health care has continued to escalate. Some reasons are legitimate (new technology, rising overhead, etc), and some reasons are not (defensive medicine, medical liability insurance premiums, siphoning of dollars out of the system as profits, mismanagement, etc). The economics of our health care delivery system is presumed to be based on capitalism, but in practice, it is not. Capitalism in its purest sense (supply and demand) does not really describe our system because there are “third parties” such as the health insurers and federal and state agencies that have a major influence or control of the health care dollars. Another significant factor which is attributable to the providers is excessive duplication of tertiary and quaternary care in the same community. Hospital-based programs such as organ transplantation, joint replacement, and cardiac surgery are profitable for the hospitals, so there is over duplication of these programs in many metropolitan centers. This aspect of “capitalism” has a negative impact on health care delivery by significantly increasing cost (by duplication of equipment, personnel, and perpetual advertising) and decreasing quality (by creating smaller programs and diffusing the specialty workforce). I practice in a metropolitan area where we have 7 transplant programs within 10 miles of each other. We have four university hospitals and several large community hospitals with tertiary/quaternary programs all competing with each other. That excessive duplication of care costs a lot of money, which could be better spent if there was some form of centralization that would more closely balance need with access,. I am definitely not implying socialized medicine, just cost reduction by adjusting services to the demographics. On a national level this would be a cost savings in the billions of dollars which could be funneled back into the health care delivery system. As mentioned earlier, the public has expectations that when they want or need health care, they should have it, whether they have any resources to pay for it or not. The issue here is not whether health care is a right or a responsibility. The reality is that it is an expectation in our culture. There is really nothing wrong with that expectation as long as it is moderated, and we can somehow pay for it.
3. Workforce The public is not informed nor do they understand that there is an overall physician workforce shortage. Furthermore,
4
M.Z. Schwartz
1,000,000 800,000 600,000
297.4
Physicians Per 100,000 Population Population is U.S. civilian population including possessions
142.2
141.6
277.4
299.2 988,100
906,278
236.9 776,301
195.9 601,237
155.6 453,165
400,000
323,799 219,897
259,443
200,000 0 1950
1960
1970
1980
1990
2000
2010
2020
Source: Bureau of Health Professions
Fig. 1 Supply of active physicians (MD and DO) and ratio to the population: actual 1950-1990 and projected 2000-2020. Note the flattening of growth beginning in 2000. Data compiled from the Bureau of Health Professions.
the public can not easily comprehend the impact of a physician shortage, especially in many of the medical and surgical specialties. I believe that this may be the tipping point for the public when access becomes a major issue for children's care. More importantly, of relevance to us is that the shortage will be greatest in the pediatric and pediatric surgical specialties. Because the public does not understand or are engaged in this issue, our elected officials, mostly at the federal level, are really not willing to get engaged in the discussion. Because workforce issues are not on the public's mind, and they are not demanding solutions, it is not going to be a priority for Congress or the President. Why? Because it is not yet a basis for determining the public's vote and thus, determining their re-election. Their primary responsibility if they want to stay in office, is to respond to their constituents, and if this is not on the radar screen of their constituents, it is not going to be their priority. We train a lot of doctors in the United States, and we also recruit them from other countries. Fig. 1 shows the increase in physicians starting from 1950 to what is projected to 2020. There is a leveling off between 2010 and 2020. This is concerning because our population is not equally distributed by age. We have this large influx of “baby boomers” that are 80 million strong and entering the age at which a large percentage will require health care. What has been able to compensate for the workforce shortfall so far is the significant increase in physician assistants and nurse practitioners (Fig. 2). Physician extenders can handle a moderate amount of what a primary care physician does, but they are limited when it comes to enhancing the surgery workforce. They can help us in the operating room, but they cannot operate. However, it was the Academy of Family Physicians who lobbied Congress about the shortage of primary care physicians that received all of the attention in Washington, DC. Serious attention by Congress regarding the impending workforce shortage is unlikely to occur because the funding for resident training comes from Medicare, and there has
been a moratorium on all new resident positions since 1997. An even bigger issue facing General Surgery is the fact that there has been a dramatic progression by surgery residents to elect fellowship training, which is now estimated to be ≥80%! This is a major problem because we still need general surgeons in community hospitals, rural hospitals, and to provide care that specialists may no longer have in their skill set. In fact, this is already a major concern for finishing residents in General Surgery that completed a fellowship. Within a short period of time they are telling their community hospital administrations and medical staffs that they do not feel qualified anymore to take general surgery call for the emergency department. Thus, this will create a real access to care problem in this country in the near future. Another issue is the General Surgery aging workforce. Thirty-five percent of the surgical workforce is over 55 years of age. By 2014 that number is predicted to jump to 42 percent. Thus, a large group of surgical practitioners are going to retire soon, and we will not have sufficient backfill to accommodate the demand. Shown in Fig. 3 is the distribution of general surgeons in the United States. The largest blue circles indicate the greatest number of general surgeons per capita. They are concentrated in the major population areas mostly in the Northeast, likely because of the large number of training programs in teaching hospitals in the Northeast corridor and also other regions such as Southern California. The Pediatric Surgery workforce is and will become an even greater access problem in the future. There are currently approximately 780 to 800 practicing pediatric surgeons in the United States (Fig. 4). It is estimated that there are approximately 80-100 open positions in Pediatric Surgery in the United States at the present time. Thus, the supply clearly does not meet the demand. Currently, recruitment of a pediatric surgeon has become very challenging. The number
Cumulative growth since 1990 % rate of growth (cumulative) since 1990
Supply (Thousands)
Supply of Active Physicians (MD & DO) and Ratio to Population Actual 1950-1990 and Projected 2000-2020
250 Nurse Practitioners 247%
200
150
Physician
Assistants 152%
100
50 Physicians 32.2%
0
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002
Year
Fig. 2 Cumulative growth of physicians, physicians assistants, and nurse practitioners. Note the significant growth in physicians assistants and nurse practitioners in contrast to physicians. Data compiled from the Bureau of Health Professions.
Health care quality, access, cost
Distribution of surgeons by county in 2006. Note the high concentration in the northeast and southern California.
of training programs in Pediatric Surgery has gradually increased over time. Recently, there have been more applications for new Pediatric Surgery fellowships. However, it still does not meet the demand. At present there are 41 Accreditation Council for Graduate Medical Education (ACGME)–approved training programs in Pediatric Surgery in the US and 6 programs in Canada. Some of the programs in the United States are limited to one trainee every other year. Approval of new programs is based on an application to the Surgery RRC that successfully meets the ACGME defined program requirements. There has been a long standing misconception that the field of Pediatric Surgery can control the number of training slots. This is not correct. The fact is that if a program applies and meets the ACGME criteria, the program must be approved. The other misconception is that the criteria are so demanding that relatively few programs qualify. This is also not the case. Thus, the Surgery Residency Review Committee (RRC) decision about approval of training programs, whether it is Pediatric Surgery, General Surgery, or Vascular Surgery, is based on the defined educational criteria. It can not be based on need or economics. In fact, this would be restraint of trade, which is a federal felony. Fig. 4 illustrates data from the American College of Surgeons (ACS) Health Policy Research Institute on the
number of pediatric surgical specialists from 1981 to 2006. When I first saw this data, I was alarmed, not so much with the Pediatric Surgery numbers but the very low numbers of
Pediatric Surgical Supply, 1981 - 2006 Number of Pediatric Surgeons
Fig. 3
5
800 700 600 500 400 300 200 100 1981
1986
Pediatric Surgery Pediatric Urology
1991
1996
Pediatric Orthopedics Pediatric Neurological Surgery
2001
2006
Pediatric Ophthalmology Pediatric Otolaryngology
Pediatric Cardiothoracic Surgery
Source: AMA Physician Masterfile data, 1981 – 2006. Produced by the American College of Surgeons Health Policy Research Institute.
Fig. 4 Number of pediatric general surgeons and pediatric surgical specialists by specialty from 1981 to 2006. The data from 1981 to 1991 includes all pediatric surgeons combined because the data was lacking on specific specialties. The data from 1996 to 2006 represent data for all specialties. Note how few pediatric surgical practitioners there are in 2006.
6 the pediatric surgery subspecialists. I frequently mention Pediatric Neurosurgery for two reasons: (1) Currently, there are only approximately 130 practicing pediatric neurosurgeons in the United States with an average age of 55 years old, and (2) there are only 10 training programs in Pediatric Neurosurgery in the United States. However, in the last few years, no more than 50% of these training slots have filled! With only approximately 5 trainees in Pediatric Neurosurgery per year, and with half of the workforce 55 years old or older now, there is looming a major access to care problem. Whereas there is crossover in skills and training in some surgical specialties, who is the crossover or backfill for a pediatric neurosurgeon? Who can treat a newborn with hydrocephalus or a 2-year old with a brain tumor besides a pediatric neurosurgeon? This is a major unaddressed concern, but it is not unique to Pediatric Neurosurgery. There are many pediatric and pediatric surgical specialties facing significant workforce shortages including pediatric general surgery. Where are we going to be in 10 years? Fig. 5 is a map showing the distribution of pediatric surgeons, both general pediatric surgeons, and pediatric surgical specialists, in the United States as of 2006. Similar to the general surgery
M.Z. Schwartz map, you have the same concentrated areas where pediatric surgeons are located. Note that parts of the Midwest and Northwest are poorly covered by pediatric surgeons. That is concerning because of the travel distance necessary to find a pediatric surgeon. This could create a life or death situation and probably does. To summarize, we have a looming workforce shortage which will be more of an issue in the specialty areas then primary care because of the lack of crossover or backfill for the pediatric surgery providers.
4. Surgical education Another factor that contributes to our health care delivery system is surgical education, and it is also under attack. From the vantage point of Congress and the President, GME is an easy target because the funding comes from Medicare, and reduction in funding would not be initially understood to impact the public. Furthermore, the academic world probably does not have the financial or political clout to prevent it from happening. The major academic oversight
Fig. 5 Number of pediatric general surgeons and pediatric surgical specialists by county in 2006. Note the significant concentration in the northeast and southern California.
Health care quality, access, cost in America includes the Association of American Medical Colleges (AAMC); American Board of Medical Specialties (ABMS) ,which includes the American Board of Surgery; and the ACGME, which includes the Surgery Residency Review Committee (RRC). I believe there is confusion and misunderstanding about these organizations and how they arose and where their authority comes from. The AAMC is a private, nonprofit organization which started in 1876 and initially represented 22 medical schools. Today, the AAMC represents all 135 accredited US and 17 accredited Canadian medical schools; approximately 400 major teaching hospitals and health systems, including 62 Department of Veterans Affairs medical centers; and nearly 90 academic and scientific societies. Through these institutions and organizations, the AAMC represents 125,000 faculty members, 75,000 medical students, and 106,000 resident physicians. The ACGME is a private, nonprofit council. It is not a government agency, and although the government certainly has some influence over medical education, it does not directly control the ACGME. The mission of the ACGME is to define medical specialty training program educational criteria and evaluate and accredit residency training programs in the United States. It was established in 1981. Thus, it is not as long standing as long as one would think. There are currently 8,734 ACGME accredited residency programs involving 130 specialties and subspecialties. Under the ACGME umbrella, there are 28 review committees, 26 of which are focused on medical or surgical specialties. Under the umbrella of the Surgery RRC are General Surgery, Vascular Surgery, Surgical Critical Care, and Pediatric Surgery. The RRC has some mobility in setting standards for their respective specialty areas, but the overarching educational goals are defined by the ACGME structure. The ABMS is also a private, nonprofit organization that dates back to 1933. Under the ABMS umbrella, there are 24 medical and surgical specialty boards, and their primary roles are to evaluate and certify trainees as competent in the field for which they have trained and to define the criteria to recertify practitioners in those specialties. Thus, the AAMC helps to define medical school education, the ACGME accredits training programs, and the ABMS certifies trainees and recertifies practitioners. It should be noted again that all three of these organizations are private and not directly governed by Congress or the Executive Branch. However, the influence of the government is not without significance, specifically as it relates to funding, work hours, etc., through congressional mandates or Institute of Medicine recommendations. The impact of funding for graduate medical education by the Federal government is significant. In 1969, when the Medicare Act was passed, it included funding provisions for GME. This really opened the door for expansion of training programs and trainees in hospitals. Currently, each accredited training program receives approximately $100,000 per trainee per year. A major university Medical Center with
7 several accredited training programs will receive millions of dollars. Overall, the Government funding for GME is around $9.5 billion a year. A substantial reduction in these funds would have a major negative impact on the number of residents being trained, resident education, as well as a significant impact on hospital budgets. What has added to this dilemma is the Balanced Budget Act of 1997, which instituted a moratorium on funding for new GME slots. Thus, there has been no new funded GME positions since 1997. That is why you see the growth curves in workforce flattening out and will become completely flat. Some of the hospitals are willing to pay for residency training out of their own resources which have produced a slight increase in some specialties. Our Government began to recognize, to some extent, the workforce issue and encouraged medical schools to expand their enrollment and start new medical schools. However, with no increase in funded resident training positions we are going to have a lot of medical students that will not get a residency, at least not in their specialty choice.
5. Access Finally, what about access to care? This is really the critical issue as far as the public is concerned. With all of the negative impacts on quality, workforce, education, and cost reduction, under current circumstances, it will be impossible
Fig. 6
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M.Z. Schwartz
Fig. 7
to avoid a significant negative impact on patient access. This is when the public will finally get involved in this impending crisis. Unfortunately, the damage will be done, and recovery will be difficult. The beginning of this is already occurring. We see it in our own emergency rooms and in long wait times to get appointments with certain specialists. It is good now compared to where we are headed in 5-10 years. This will be the timeframe when the public will realize what has happened and the level of agitation, frustration, and anger will increase.
Fig. 8
Fig. 9
Thus, optimum health care delivery in America really is under attack. So what can we do? As providers of pediatric surgical care, do we just have to let this happen? That would not be consistent with our profession. The surgical specialties need to avoid the usual “soapbox” demands of increased reimbursement and malpractice reform. Unfortunately, this is how surgeons are viewed in Washington, and we have little sensitivity or support from the public regarding either of these issues. The other major issue is the fragmentation of the surgical specialties. Because we have not been successful in
Fig. 10
Health care quality, access, cost reaching sufficient common ground among the major surgical specialties, we have successfully divided and conquered ourselves! We do not have an effective collective voice in Washington or even within our own state governments. During the past several decades, we have witnessed the health insurance industry gain control of the private sector health care dollars and at the same time reduce reimbursement to hospitals and to a greater extent to physicians and surgeons. In addition, we have seen the medical liability costs increase and the pharmaceutical industry also has an increasing role in the economics of health care. Thus, we are outspent and outmaneuvered by these industries. The American Medical Association (AMA), as the spokes-entity for medicine, used to have clout but for numerous reasons has also splintered within its ranks. The clout of the AMA in Washington right now has diminished substantially. We really need to create an effective and cohesive surgical coalition that can speak for the “House of Surgery,” and we need to develop strategies for Surgery to gain credibility with the public. Why? Because the public is our best ally. The public, once informed and supportive of our goals, will trump the health insurance industry, the hospital associations, big pharma, and the trial lawyers. Our best route for this success is to combine quality of care with cost reduction. The ACS has been pursuing these goals since its inception in 1913. The Joint Commission came out of efforts by the ACS. Advanced Trauma Life Support was started several decades ago, and the College played a significant role in the evolution of the Commission on Cancer. More recently, the ACS initiated the National Surgery Quality Improvement Program, which has been very successful in reducing surgical complications (and improving quality) in the member hospitals. The participating hospitals have shown a dramatic reduction in complications and therefore, health care costs. Another effort by the ACS has been to establish a Health Policy Research Institute (ACS-HPRI) to develop peer-reviewed health policy data related to surgical care. In addition, to improve the presence of the ACS and the “House of Surgery” in Washington, the College built a 10-story building that is walking distance to the Capitol. As surgeons, we have achieved a great deal of credibility. Unfortunately, we have not done a very good job in communicating it to our Government and the public. Through recent and on-going efforts, the ACS has begun a
9 campaign referred to as: “Inspiring Quality-Highest Standards, Better Outcomes.” In addition, the ACS has made an effort to bring together more than 20 surgical associations to define common goals regarding health care policy and, thus, to form a true coalition. Currently, this involves approximately 240,000 surgeons. If this coalition can solidify, it will create considerable visibility and clout in Washington. This is the path for the “House of Surgery” to gain the credibility and impact on the public and Congress that is required for us to influence the policies that will impact on us in the future. If we fail in these efforts, more federal policies will further compromise our ability to maintain the best health care delivery system. I have been extremely fortunate throughout my career and wish to acknowledge a few of the individuals that have mentored, supported, and facilitated my career: Henry Buchwald, a surgeon-scientist at the University of Minnesota, who accepted me into his laboratory and gave me my own basic science research project as a third year medical student in 1968 and has been a mentor and friend ever since (Fig. 6); John Najarian, who was the Chief of Surgery at the University of Minnesota during my general surgery residency, who was not only an excellent chairman but allowed me to bypass a senior year to do my chief year and begin pediatric surgery training in Boston one year earlier than planned (Fig. 7); Jim Thompson, Chief of Surgery at the University of Texas Medical Branch, another surgeon-scientist, who fostered my GI research career (Fig. 8); Judah Folkman, the ultimate surgeon-scientist and the most brilliant and inspiring person I have ever known, who taught me so many things by example including humanity and humility (Fig. 9); and David Tapper, who was an enormous inspiration to me, accomplished much in a very short time, and left us way too soon. He was my best friend (Fig. 10).
References [1] Hendren WH. Some reflections on the cost of health care. J Pediatr Surg 1983;18:659-69. [2] de Lorimier AA. Health care costs in a declining America. J Pediatr Surg 1993;28:281-91. [3] Grosfeld JL. Economics and education: impact on pediatric surgery in the next decade. J Pediatr Surg 1996;31:3-11. [4] Data from the Congressional Budget Office.