The public policy plan of the American Gastroenterological Association

GASTROENTEROLOGY 1992;102:3-6

AMERICAN

GASTROENTEROLOGICAL

ASSOCIATION

The Public Policy Plan of the American Gastroenterological Association

M

ajor advances in the science and practice of gastroenterology have created greater specialization and more diversity of interests among AGA members. The AGA has responded to these changes by reorganizing to better meet the needs of its diverse membership: the Governing Board recently developed a five year plan.’ Among the challenges faced by the AGA is the need to influence public polities that presently affect the interests of gastroenterologists or may do so in the future. This report summarizes the principles and processes through which the Governing Board intends to address public policy issues to further the interests of its membership. The priorities agreed to by the Governing Board are summarized and reflect the importante of the issues to the membership and the likelihood that the issues can be influenced with the resources available to the AGA. Governmental

Affairs Philosophy

The AGA expects to be the principle advocate of the GI community on issues that affect clinical practice and research. These issues include biomedical research, health care financing (including physician payment issues), and access to health care. As the public policy program evolves and members remain committed, the AGA wil1 not only react, but it wil1 initiate public policy efforts reflective of the philosophies and goals of the organization. The AGA is committed to a program of advocacy based on certain principles that wil1 govern its actions in this arena. Maintenance of its credibility as a responsible organization is a fundamental principle under which the program wil1 operate, and to this end the program wil1 be based on ability to offer constructive alternatives and rational arguments supported by credible data. Recognizing that public policy advocacy is an ongoing and long-term effort, the AGA wil1 conduct its advocacy with a view to the long term implications of its positions on its institutional credibility. The second principle governing the public policy program is presence, for without an ongoing presence when public initiatives are formed and debated, no position, no matter how wel1 developed, wil1 be heard. To this end, the AGA wil1 expand the nature and scope of its Washington activities and

broaden the range of issues it wil1 address over time. Additionally, the organization wil1 operate in a manner that wil1 assure that its presence and positions are solicited and considered by policy makers. The Governing Board regards member involvement and support of public policy initiatives as a cornerstone of the program; ultimately, individual members are the most effective advocates. Towards this goal, the AGA is enhancing communication with the membership about legislative and regulatory affairs through AGA News and special mailings and through public policy symposia during Digestive Disease Week. These efforts deal with both the substance of the issues and advice and information on how to lobby. Members are encouraged to cal1 the AGA’s Washington office (phone, 202-543-7441; fax, 202-543-5327) with questions or for information on public policy matters. To make members more confident advocates, a “Key Contact” program is being developed that involves AGA members and key members of Congress. The AGA wil1 develop and provide supporting resources to facilitate visits to members of Congress by AGA members both in Washington and in home districts. Another fundamental principle of the program is for the AGA, wherever possible, to foster consensus and work through coalitions on the issues. Coalitions and consensus bring strength to public policy initiatives. However, the organization reserves the right to act independently to further its own fundamental philosophies. Process The public policy initiatives are effected through the Public Policy Committee under the supervision of the Governing Board. The Committee’s mission is twofold: it evaluates and assesses public polities and identifies and recommends new public polities to the Governing Board in light of the needs and interests of the GI community; and it oversees and administers the operation of AGA public policy activities. The Public Policy Committee consists of a crosssection of the membership and meets biannually. The membership for the Committee consists of (a) the chairs and one member of the Research, Patient

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JAMES W. FRESTON

GASTROENTEROLOGY

Care, and Training and Education Committees; (b) a representative from the Clinical Section and from Digestive Disease National Coalition; (c) several atlarge members; and (d) the president of the AGA and the Washington representative ex officio. Members of the Committee may also be assigned to work on special task forces when specific issues require in-depth analysis before consideration by the entire Committee. Recommendations of the Committee on new matters and al1 forma1 AGA position papers must be approved by the Board. Congressional testimony and communications and regulatory comments also need to be approved by the Board, although in cases of well-established policy, the President, on recommendation of the Chairman of the Committee and in consultation with other Board members as needed, may approve such comments. The Chairman is to directly authorize initiatives of a noncontroversial nature if they involve minima1 tost and effort and represent implementation of clear and wel1 established AGA polities. Public Polities and Priorities Physician

Payment

Policy

The AGA supports federal polities for payment for physician services under various federal programs that are fair, equitable, and realistic with respect to treatment and diagnosis of digestive diseases. The AGA recognizes that payment for physician’s services wil1 need to change as part of an overall reform of the current system of health care financing, and it supports reform to the extent that it provides opportunitic% to expand coverage of health care programs, reflects new knowledge about the resources involved in provision of services, and is fair and equitable in principle and operation. The AGA therefore objects to the current proposals from the Health Care Finance Administration (HCFA) and wil1 work for their reform in light of the following points that are inconsistent with AGA’s position: The current HCFA proposal goes beyond Congressional intent and seeks to use physician reform as a tool to reduce the federal budget deficit. The current HCFA proposal unfairly penalized GI services by including nonincisional procedures in the definition of surgical services, contrary to the recommendation of its own experts, and, thereby, denying appropriate reimbursement for necessary care. The HCFA uses inconsistent principles in establishing reimbursement principles relating to volume of services, and has no credible data to sup-

Vol. 102, No. 1

port its approaches. The AGA supports the practice guidelines and credentialling as a to control volume, and is pursuing a study major private insurer to assess the validity approach.

use of means with a of this

The AGA is also working on a number of other issues relative to physician reimbursement and wil1 be communicating regularly to Congress, HCFA, and the Physician Payment Review Commission (PPRC) to advance AGA’s positions. Specifically, the positions involve the following: (a) necessary refine-, ments in the RBRVS as it is phased in between 1992 and 1995; (b) securing the increases in the evaluation and management fees as originally contemplated in the RBRVS study and as pledged by Congress; (c) developing appropriate polities that wil1 reduce the volume of unnecessary services; and (d) recommending appropriate changes to coding for gastroenterology services, based on the recommendation of the Patient Care Committee as it monitors the activities of the Current Procedural Terminology Panel. Biomedical

Research

The AGA supports increased National Institutes of Health (NIH) and Veterans Administration (VA) funding for biomedical research. The Governing Board is concerned that the absente of a cohesive message regarding funding needs from a united biomedical research community may be compromising efforts to increase the budget of the NIH. The AGA. wil1 pursue the possibility of developing and gaining Congressional and Administration support for a 5year plan for program growth and required funding increases for the NIH. A similar plan has rationalized the planning and funding of the National Science Foundation. This plan wil1 not attempt to prioritize areas of science. Rather it wil1 attempt to define the necessary balance among mechanisms of support (e.g., investigator-initiated grants, training grants, institutional support, clinical trials, research centers, and research infrastructure). To succeed, this initiative must be undertaken in collaboration with many other organizations representing biomedical researchers, research institutions, and voluntary organizations. In the meantime, the Public Policy Committee wil1 (a) expand efforts to achieve sizable funding increases for the NIH as wel1 as the VA medical research program and (b) develop recommendations for a program to educate the public regarding. the importante of biomedical research and the need to expand funding opportunities (with particular emphasis on research on digestive diseases). In the course of these efforts, the AGA wil1 heighten congressional awareness of the organization’s role as a sponsor of research that might otherwise go unfunded because of the inadequacy of sup-

PLJBLIC POLICY PLAN

January 1992

port available from federal agencies and other sponsors. The Research Committee, with advice from the Research Council, wil1 develop a plan for prioritizing the research program for digestive diseases. This plan wil1 prioritize scientific questions in the field and assess the need for changes in the organization/ integration of gastroenterological research within the NIH and the VA research programs. In addition, specific goals wil1 be set in terms of the mechanisms of support for research on digestive diseases (e.g., investigator-initiated grants, centers, trainees). The Governing Board believes that such a plan wil1 help assure that limited funding for digestive diseases research is allocated wisely. Ultimately, the AGA leadership wil1 transmit this plan to the NIH, the VA, and the National Digestive Diseases Advisory Board and wil1 work with these groups toward its implementation. Graduate

Medical Education

The AGA supports efforts to define the appropriate manpower needs of medical specialities for the future and recognizes the long term need to address manpower issues. To support such policy development, the AGA Training and Education Committee wil1 develop recommendations for the content of training in gastroenterology. Additionally, gastroenterology manpower wil1 be addressed in light of training, practice, research, and demographic issues. This effort wil1 help facilitate the development of data necessary for a rational and effective approach to the future manpower needs in gastroenterology. Based on assessment of these data, the Public Policy Committee wil1 explore the alternative approaches to a rational manpower policy in terms of federal payment and other polities. The AGA does not support and wil1 actively oppose any changes in the Medicare graduate medical education (GME) policy intended to regulate or control manpower policy or to create incentives or disincentives for GME program support. In the case of gastroenterology, such changes would be premature in light of the efforts of the profession to develop a manpower projection and act upon it. The policy wil1 be ineffective since the payment levels are grouped into overall hospita1 payments and do not directly affect individual program. The policy wil1 adversely affect underserved areas, where GME is used to support medical service needs for the poor and underinsured. Access to Care The AGA believes that al1 Americans should have access to a single leve1 of high quality medical

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care within a system that is administratively simple, fair, and equitable to patients, providers, and payors. Access to care wil1 clearly be one of the most contentious issues on the American Agenda for the next several years. As the debate on passage and repeal of the Medicare Catastrophic Coverage Act showed, who benefits, who pays, and what gets covered arouse passions on al1 sides of a complex issue. As Congress begins to address access to health care in terms of the needs of an aging population for longterm care, in terms of basic health care for the poor and uninsured, and in terms of federal programs that are concededly broken but which nobody knows how to fix, the AGA wil1 participate in that debate. The AGA intends to assess proposals against its basic policy that establish three basic benchmarks: (a) access, the extent to which existing resources are reallocated on the basis of tost and benefit to improve accessibility; (b) quality, the extent to which the system promotes sensible medical care; and (c) tost, the extent to which the system is fair and equitable to providers of care. As the debate on the issue becomes more focused, the AGA wil1 refine and expand these evaluative criteria. The AGA wil1 also explore the implications of a voluntary system to provide care to the poor and the uninsured, possibly through a clearinghouse arrangement in which the AGA facilitates arrangements between its members and patients. Although the legal, practical, and ethica1 implications of such a proposal remain to be assessed, initiations of such an effort would be a profound expression on the part of AGA members and, perhaps, a model for al1 of medicine to consider. Colorectal

Cancer Screening

The AGA supports Medicare coverage of appropriate colorectal cancer surveillance. The organization advocates the adoption of federal legislation to provide appropriate screening blood stool tests and flexible sigmoidoscopy for Medicare beneficiaries to detect colorectal cancer in an early stage. This approach should be tost efficient based on expenditures and savings to Medicare. Through the Research Committee, the AGA wil1 continue to assess research findings on the costs and benefits of colorectal cancer screening. Conclusion

The AGA public policy program reflects an increased commitment to a more visible, aggressive, and thoughtful advocacy. As with most programs of this nature, it wil1 evolve in sophistication and scope over the next few years. The goal is to be the most

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6 JAMES W. FRESTON

effective advocate on public policy initiatives for AGA members, for the digestive disease community, and, most importantly, for our patients. A critical element of this program is the support and involvement of the membership. Members should provide ideas, comments, criticisms, and suggestions about the issues and operations of the public policy program; such input is the best way for the AGA to be sure that it is addressing members’ priorities. Members also need to become personally involved in influencing public policy; the AGA wil1 support and assist members in their involvement as informed and responsible individuals. Between the AGA’s institutional commitments and the members’

efforts, the public policy programs ference.

wil1 make a dif-

JAMES W. FRESTON

Chairman,

Public Policy Committee

References 1. Alpers DH. A five-year plan of the American Gastroenterological Association. Gastroenterology 1991;100:301-304.

Address requests for reprints to: James W. Freston, M.D., Ph.D., Department of Medicine LG-006, University of Connecticut Health Center, 263 Farmington Avenue, Farmington, CT 06030. 0 1992 by the American Gastroenterological Association 0016-5085/92/$3.00