Clinical Review & Education
Special Communication
American Surgery and the Affordable Care Act Steven C. Stain, MD; David B. Hoyt, MD; John G. Hunter, MD; Geoffrey Joyce, PhD; Jonathan R. Hiatt, MD
The Affordable Care Act (ACA) attempts to change the way we finance and deliver health care by coordinating the delivery of primary, specialty, and hospital services in accountable care organizations. The ways in which accountable care organizations will develop and evolve is unclear; however, the effects on surgeons and their patients will be substantial. High-value care in the ACA emphasizes quality, safety, resource use and appropriateness, and the patient’s experience of care. Payment will be linked to these principles. Department chairs overseeing a clinical enterprise in academic medical centers now must add financial and quality measures to the traditional missions of education, research, and clinical service. At a time when surgical training is in dramatic evolution, with work hour limitations for residents and an emphasis on quality, productivity, and increasing oversight of trainees for faculty, residency programs will need to meet the increasing demands of an aging population and newly insured patients under the ACA. The American College of Surgeons, with its century-long commitment to quality improvement, research-based standards, and performance measurement and verification, has begun its Inspiring Quality Campaign, is developing new educational tools, and is preparing proposals for payment reform based on surgeons’ participation in quality programs. JAMA Surg. 2014;149(9):984-985. doi:10.1001/jamasurg.2014.1343 Published online August 6, 2014.
T
he statistics are sobering. Per capita health care spending in the United States is 50% to 100% higher than it is in Europe, Canada, or Japan, and the quality of health care is no better or worse between the United States and those countries by most metrics. The United States has a private health care system, yet about half of the $2.8 trillion spent annually is paid by government entities. If this fiscal burden continues, the federal government will continue to run budget deficits during periods of economic growth and there will be fewer funds to support education, national security, and government investment more broadly. This is the context for reforming health care. The Affordable Care Act (ACA) attempts to change the way we finance and deliver health care. A cornerstone of the program is the development of accountable care organizations (ACOs), which are networks of providers and hospitals that share financial and medical responsibility for providing care to a group of patients. The aim of the ACO is to coordinate the delivery of primary, specialty, and hospital services in one package, with the incentive that the providers and hospitals share in the savings if they deliver high-quality care at less than the projected cost. How ACOs will develop and evolve is unclear. Two formulations are proposed: physician-controlled ACOs, with physicians affiliating and contracting with hospitals and controlling the flow of funds, and hospital-controlled ACOs that will employ physicians.1 Because much of the savings will come from successfully avoiding high-cost procedures and hospitalizations, specialists and hospitals appear to have the most to lose. However, if the ACO is run by the hospitals, the hospitals will accrue more of the savings and physicians’ incomes and status as independent professionals will be under pressure. 984
Author Affiliations: Department of Surgery, Albany Medical College, Albany, New York (Stain); American College of Surgeons, Chicago, Illinois (Hoyt); Department of Surgery, Oregon Health Sciences University, Portland (Hunter); Schaeffer Center for Health Policy and Economics, Department of Pharmaceutical Economics and Policy, University of Southern California, Los Angeles (Joyce); Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles (Hiatt). Corresponding Author: Jonathan R. Hiatt, MD, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, 10833 Le Conte Ave, 12-138 Center for the Health Sciences, Los Angeles, CA 90095 ([email protected]).
Department chairs in academic medical centers are still asked to meet the tripartite missions of education, research, and clinical service, but the emphasis increasingly has been placed on the clinical enterprise to fund the other components. The focus on reducing health care costs suggests a fourth mission for department chairs: achieving financial results that require us to simultaneously reduce costs of care and maximize reimbursement by achieving quality objectives. It will be difficult to achieve the fourth mission as long as quality incentives represent only 2% of the revenue at a typical academic health center. Unless we invest in order to protect reimbursement, we will be unable to truly bend the cost curve.2 From the perspective of general surgery training, it is clear that the demand for surgical services will increase with our aging population and patients newly insured under the ACA. This demand comes at a time when training is in dramatic evolution with work hour limitations for residents and an emphasis on quality, productivity, and increasing oversight of trainees for faculty. Several recent studies3,4 have demonstrated that operations performed by residents are 20% to 50% longer and may have higher complication rates compared with those performed by experienced surgeons. Although few would argue that learning takes time, the complication data can be challenged by the differences in patient as well as system complexity in most academic medical centers. It has been estimated5 that we will need a 10% to 15% increase in the work force to cover the 10% increase in our insured population. Medical schools have responded by adding 10 000 new spots for students and more osteopathic schools are being established; however, the number of graduate medical education positions remains static with no increase in federal funding. There was discussion of increasing graduate medical education funding in the ACA,
JAMA Surgery September 2014 Volume 149, Number 9
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a Penn State Milton S Hershey Med Ctr User on 05/28/2015
jamasurgery.com
American Surgery and the Affordable Care Act
Special Communication Clinical Review & Education
but this provision was pulled from the final iteration with the idea that hospitals and/or insurance companies should be expected to fund the new positions. Unionization of trainees may drive costs even higher. The ACA is designed to improve access to care through insurance reform, provide for payment reform by exploring several different payment models, and redesign the delivery system through performance measurement and selection of best care. For the first time, quality improvement is a shared interest and mission of the Department of Health and Human Services, under the National Strategy for Quality Improvement in Healthcare, and the philosophy of a so-called triple aim (improving patient experience, improving health of populations, and reducing per capita costs) that the Centers for Medicare and Medicaid Services has adopted.6 Overall, the national strategy will emphasize high-value care through a process of selection of quality priorities and performance measurement from data streams aggregated to measure care effectiveness and cost. High-value care in the ACA emphasizes quality, safety, resource use and appropriateness, and the patient’s experience of care. Ultimately, measures reflecting each of these factors will be embedded in the performance assessment, and payment will be linked to these principles. Specific programs have begun to link payment to performance measures such as hospital-acquired infections and readmissions. The health care culture is perhaps the most important feature that still is being defined. It will emphasize patient centeredness, a commitment of leadership, engagement of employees, and a culture of safety in which transparency and performance improvement are linked to accountability. Many organizations have achieved this, and we must accelerate the pace at which organizations can learn these principles and apply them. The American College of Surgeons has been committed to quality improvement for a century by setting research-based standards, completing the infrastructure to deliver care as described in the standards, and measuring and verifying performance using
registries, outcomes assessment, and external peer review. The future of quality will emphasize high value, high reliability, and the identification of positive outliers to inform and improve the system overall. The experience of the American College of Surgeons with the National Surgical Quality Improvement Program database has proven that this model is feasible and can be replicated by multiple hospitals and lead to significant cost savings. The American College of Surgeons has begun its Inspiring Quality Campaign and, based on more than 15 visits to communities around the United States, has learned that quality is measureable, high-quality data are essential, quality thrives in a supportive culture, and collaboration among providers spurs innovation. Recognizing that surgeons must lead in quality in the operating room, on Capitol Hill, and in their institutions, the American College of Surgeons is developing a manual for members to teach each other how to reach these goals and has begun to prepare proposals for payment reform based on surgeons’ participation in quality programs. We are still in the learning stages as to what is considered “best payment” and how to link quality measurement to payment. The proposed Sustainable Growth Rate Repeal and Medicare Provider Payment Modernization Act of 2014 had many elements of a meritbased incentive payment system for quality, resource use, meaningful use, and clinical practice improvement activities.7 The American College of Surgeons supports these principles, and although the law has not been enacted, we believe it will frame the discussion going forward. Health care reform needs to be realistic, and it needs input as to what will work. Without the participation of surgeons in the process, in particular through the regulatory phase, the reform is likely to be ineffective. Our leadership is our credibility and our strongest opportunity. This is really about our patients and the public trust. We are committed to meaningful and appropriate reform with the same dedication and depth of commitment that we bring to the care of our patients every day, as well as to our research and training of future generations of surgeons.
ARTICLE INFORMATION
REFERENCES
Accepted for Publication: May 16, 2014.
1. Kocher R, Sahni NR. Physicians versus hospitals as leaders of accountable care organizations. N Engl J Med. 2010;363(27):2579-2582.
Published Online: August 6, 2014. doi:10.1001/jamasurg.2014.1343. Conflict of Interest Disclosures: Dr Hoyt is executive director of the American College of Surgeons. Drs Stain, Hunter, and Hiatt are members of the American College of Surgeons. No other disclosures are reported. Previous Presentation: This information was presented at the President’s Panel at the 85th Annual Meeting of the Pacific Coast Surgical Association; February 16, 2014; Dana Point, California.
jamasurgery.com
2. Shortell SM. Bending the cost curve: a critical component of health care reform. JAMA. 2009;302 (11):1223-1224. 3. Davis SS Jr, Husain FA, Lin E, Nandipati KC, Perez S, Sweeney JF. Resident participation in index laparoscopic general surgical cases: impact of the learning environment on surgical outcomes. J Am Coll Surg. 2013;216(1):96-104. 4. Krell RW, Birkmeyer NJ, Reames BN, Carlin AM, Birkmeyer JD, Finks JF; Michigan Bariatric Surgery
Collaborative. Effects of resident involvement on complication rates after laparoscopic gastric bypass. J Am Coll Surg. 2014;218(2):253-260. 5. Kirch DG, Henderson MK, Dill MJ. Physician workforce projections in an era of health care reform. Annu Rev Med. 2012;63:435-445. 6. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff (Millwood). 2008:27(3):759-769. 7. Text of the SGR Repeal and Medicare Provider Payment Modernization Act of 2014. H.R. 4015 (113th). https://www.govtrack.us/congress/bills/113 /hr4015/text. Published March 14, 2014. Accessed June 17, 2014.
JAMA Surgery September 2014 Volume 149, Number 9
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a Penn State Milton S Hershey Med Ctr User on 05/28/2015
985
Special Communication
American Surgery and the Affordable Care Act Steven C. Stain, MD; David B. Hoyt, MD; John G. Hunter, MD; Geoffrey Joyce, PhD; Jonathan R. Hiatt, MD
The Affordable Care Act (ACA) attempts to change the way we finance and deliver health care by coordinating the delivery of primary, specialty, and hospital services in accountable care organizations. The ways in which accountable care organizations will develop and evolve is unclear; however, the effects on surgeons and their patients will be substantial. High-value care in the ACA emphasizes quality, safety, resource use and appropriateness, and the patient’s experience of care. Payment will be linked to these principles. Department chairs overseeing a clinical enterprise in academic medical centers now must add financial and quality measures to the traditional missions of education, research, and clinical service. At a time when surgical training is in dramatic evolution, with work hour limitations for residents and an emphasis on quality, productivity, and increasing oversight of trainees for faculty, residency programs will need to meet the increasing demands of an aging population and newly insured patients under the ACA. The American College of Surgeons, with its century-long commitment to quality improvement, research-based standards, and performance measurement and verification, has begun its Inspiring Quality Campaign, is developing new educational tools, and is preparing proposals for payment reform based on surgeons’ participation in quality programs. JAMA Surg. 2014;149(9):984-985. doi:10.1001/jamasurg.2014.1343 Published online August 6, 2014.
T
he statistics are sobering. Per capita health care spending in the United States is 50% to 100% higher than it is in Europe, Canada, or Japan, and the quality of health care is no better or worse between the United States and those countries by most metrics. The United States has a private health care system, yet about half of the $2.8 trillion spent annually is paid by government entities. If this fiscal burden continues, the federal government will continue to run budget deficits during periods of economic growth and there will be fewer funds to support education, national security, and government investment more broadly. This is the context for reforming health care. The Affordable Care Act (ACA) attempts to change the way we finance and deliver health care. A cornerstone of the program is the development of accountable care organizations (ACOs), which are networks of providers and hospitals that share financial and medical responsibility for providing care to a group of patients. The aim of the ACO is to coordinate the delivery of primary, specialty, and hospital services in one package, with the incentive that the providers and hospitals share in the savings if they deliver high-quality care at less than the projected cost. How ACOs will develop and evolve is unclear. Two formulations are proposed: physician-controlled ACOs, with physicians affiliating and contracting with hospitals and controlling the flow of funds, and hospital-controlled ACOs that will employ physicians.1 Because much of the savings will come from successfully avoiding high-cost procedures and hospitalizations, specialists and hospitals appear to have the most to lose. However, if the ACO is run by the hospitals, the hospitals will accrue more of the savings and physicians’ incomes and status as independent professionals will be under pressure. 984
Author Affiliations: Department of Surgery, Albany Medical College, Albany, New York (Stain); American College of Surgeons, Chicago, Illinois (Hoyt); Department of Surgery, Oregon Health Sciences University, Portland (Hunter); Schaeffer Center for Health Policy and Economics, Department of Pharmaceutical Economics and Policy, University of Southern California, Los Angeles (Joyce); Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles (Hiatt). Corresponding Author: Jonathan R. Hiatt, MD, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, 10833 Le Conte Ave, 12-138 Center for the Health Sciences, Los Angeles, CA 90095 ([email protected]).
Department chairs in academic medical centers are still asked to meet the tripartite missions of education, research, and clinical service, but the emphasis increasingly has been placed on the clinical enterprise to fund the other components. The focus on reducing health care costs suggests a fourth mission for department chairs: achieving financial results that require us to simultaneously reduce costs of care and maximize reimbursement by achieving quality objectives. It will be difficult to achieve the fourth mission as long as quality incentives represent only 2% of the revenue at a typical academic health center. Unless we invest in order to protect reimbursement, we will be unable to truly bend the cost curve.2 From the perspective of general surgery training, it is clear that the demand for surgical services will increase with our aging population and patients newly insured under the ACA. This demand comes at a time when training is in dramatic evolution with work hour limitations for residents and an emphasis on quality, productivity, and increasing oversight of trainees for faculty. Several recent studies3,4 have demonstrated that operations performed by residents are 20% to 50% longer and may have higher complication rates compared with those performed by experienced surgeons. Although few would argue that learning takes time, the complication data can be challenged by the differences in patient as well as system complexity in most academic medical centers. It has been estimated5 that we will need a 10% to 15% increase in the work force to cover the 10% increase in our insured population. Medical schools have responded by adding 10 000 new spots for students and more osteopathic schools are being established; however, the number of graduate medical education positions remains static with no increase in federal funding. There was discussion of increasing graduate medical education funding in the ACA,
JAMA Surgery September 2014 Volume 149, Number 9
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a Penn State Milton S Hershey Med Ctr User on 05/28/2015
jamasurgery.com
American Surgery and the Affordable Care Act
Special Communication Clinical Review & Education
but this provision was pulled from the final iteration with the idea that hospitals and/or insurance companies should be expected to fund the new positions. Unionization of trainees may drive costs even higher. The ACA is designed to improve access to care through insurance reform, provide for payment reform by exploring several different payment models, and redesign the delivery system through performance measurement and selection of best care. For the first time, quality improvement is a shared interest and mission of the Department of Health and Human Services, under the National Strategy for Quality Improvement in Healthcare, and the philosophy of a so-called triple aim (improving patient experience, improving health of populations, and reducing per capita costs) that the Centers for Medicare and Medicaid Services has adopted.6 Overall, the national strategy will emphasize high-value care through a process of selection of quality priorities and performance measurement from data streams aggregated to measure care effectiveness and cost. High-value care in the ACA emphasizes quality, safety, resource use and appropriateness, and the patient’s experience of care. Ultimately, measures reflecting each of these factors will be embedded in the performance assessment, and payment will be linked to these principles. Specific programs have begun to link payment to performance measures such as hospital-acquired infections and readmissions. The health care culture is perhaps the most important feature that still is being defined. It will emphasize patient centeredness, a commitment of leadership, engagement of employees, and a culture of safety in which transparency and performance improvement are linked to accountability. Many organizations have achieved this, and we must accelerate the pace at which organizations can learn these principles and apply them. The American College of Surgeons has been committed to quality improvement for a century by setting research-based standards, completing the infrastructure to deliver care as described in the standards, and measuring and verifying performance using
registries, outcomes assessment, and external peer review. The future of quality will emphasize high value, high reliability, and the identification of positive outliers to inform and improve the system overall. The experience of the American College of Surgeons with the National Surgical Quality Improvement Program database has proven that this model is feasible and can be replicated by multiple hospitals and lead to significant cost savings. The American College of Surgeons has begun its Inspiring Quality Campaign and, based on more than 15 visits to communities around the United States, has learned that quality is measureable, high-quality data are essential, quality thrives in a supportive culture, and collaboration among providers spurs innovation. Recognizing that surgeons must lead in quality in the operating room, on Capitol Hill, and in their institutions, the American College of Surgeons is developing a manual for members to teach each other how to reach these goals and has begun to prepare proposals for payment reform based on surgeons’ participation in quality programs. We are still in the learning stages as to what is considered “best payment” and how to link quality measurement to payment. The proposed Sustainable Growth Rate Repeal and Medicare Provider Payment Modernization Act of 2014 had many elements of a meritbased incentive payment system for quality, resource use, meaningful use, and clinical practice improvement activities.7 The American College of Surgeons supports these principles, and although the law has not been enacted, we believe it will frame the discussion going forward. Health care reform needs to be realistic, and it needs input as to what will work. Without the participation of surgeons in the process, in particular through the regulatory phase, the reform is likely to be ineffective. Our leadership is our credibility and our strongest opportunity. This is really about our patients and the public trust. We are committed to meaningful and appropriate reform with the same dedication and depth of commitment that we bring to the care of our patients every day, as well as to our research and training of future generations of surgeons.
ARTICLE INFORMATION
REFERENCES
Accepted for Publication: May 16, 2014.
1. Kocher R, Sahni NR. Physicians versus hospitals as leaders of accountable care organizations. N Engl J Med. 2010;363(27):2579-2582.
Published Online: August 6, 2014. doi:10.1001/jamasurg.2014.1343. Conflict of Interest Disclosures: Dr Hoyt is executive director of the American College of Surgeons. Drs Stain, Hunter, and Hiatt are members of the American College of Surgeons. No other disclosures are reported. Previous Presentation: This information was presented at the President’s Panel at the 85th Annual Meeting of the Pacific Coast Surgical Association; February 16, 2014; Dana Point, California.
jamasurgery.com
2. Shortell SM. Bending the cost curve: a critical component of health care reform. JAMA. 2009;302 (11):1223-1224. 3. Davis SS Jr, Husain FA, Lin E, Nandipati KC, Perez S, Sweeney JF. Resident participation in index laparoscopic general surgical cases: impact of the learning environment on surgical outcomes. J Am Coll Surg. 2013;216(1):96-104. 4. Krell RW, Birkmeyer NJ, Reames BN, Carlin AM, Birkmeyer JD, Finks JF; Michigan Bariatric Surgery
Collaborative. Effects of resident involvement on complication rates after laparoscopic gastric bypass. J Am Coll Surg. 2014;218(2):253-260. 5. Kirch DG, Henderson MK, Dill MJ. Physician workforce projections in an era of health care reform. Annu Rev Med. 2012;63:435-445. 6. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff (Millwood). 2008:27(3):759-769. 7. Text of the SGR Repeal and Medicare Provider Payment Modernization Act of 2014. H.R. 4015 (113th). https://www.govtrack.us/congress/bills/113 /hr4015/text. Published March 14, 2014. Accessed June 17, 2014.
JAMA Surgery September 2014 Volume 149, Number 9
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a Penn State Milton S Hershey Med Ctr User on 05/28/2015
985
