Today’s installment: My life as a policy wonk

Last weekend was an important weekend in Washington DC, not just because of the opening of the National Museum of African American History and Culture, but because it was the Fall meeting of the American College of Surgeons Health Policy and Advocacy Group (HPAG).  For those who aren’t familiar, the HPAG is the leadership group within the College that works on political issues on our behalf as an organization.  For years, the HPAG was incredibly focused (almost singularly so) on SGR repeal.  Now that we’ve checked that box, the HPAG has been able to move on to a broader variety of issues; some of these are around MACRA, the replacement for SGR, and many of them are not. Today’s blog mission is to let you know what our key HPAG topics were last weekend, and to start to educate my surgeons readers on those issues.

So…in agenda order…my take on our top 3 topics from theFall 2016 HPAG meeting-

GME– A small group has spent the last 9 months (oh, that timing seems appropriate!) developing a white paper on GME that can be used in discussions with members of Congress and their staff. Meaningful GME reform, as we are describing it, includes the components of workforce, finance, accountability, and governance. Within these four areas, the white paper includes the following proposed steps:

  • Workforce- support healthcare workforce data collection and research
  • Finance- maintain current levels of GME financing and appropriate temporary additional funds to support a GME modernization and quality improvement program
  • Accountability- combine DME and IME into a single stream of GME funds
  • Governance- move toward a regionalized GME governance system

While this gives you a crude outline of what the GME workforce group proposed, I hope to share more with you about this in a month or so once it is approved by the ACS Board of Regents. This is an area I’m particularly excited about because of my own roles in surgical education, and because it represents an opportunity for our profession to lead.  Change is coming to GME; this is our chance as surgeons to help define what that change looks like.

Global codes data collection– CMS has proposed onerous data collection around 10-day and 90-day global codes. The current proposal is for ALL practitioners who provide services under these codes to collect data on ALL patients served under these codes and for ALL services other than the procedure. G-codes were developed in conjunction with SAGE that require reporting of care in 10-minute increments, and using vague descriptors of “typical,” “complex,” and “critical.” The one that is most interesting to me as a burn surgeon is that “change dressings” is included as a typical visit.  Anyone who has spent any amount of time in a burn clinic knows that our dressing changes are anything but typical, and really don’t belong in the same category as a dressing change on a patient who had laparoscopic surgery.  Also, this idea of 10-minute time increment reporting strikes me as ludicrous because it is entirely inconsistent with any workflow (and quite frankly, would interfere with providing actual patient care, which is what I believe I’m supposed to be doing). The ACS is asking CMS to alter their plans to only obtain data from a representative sample of physicians and to avoid use of the unvalidated G-codes.  Again, stay tuned…I’m sure there is more to come on this, including an ask for people to reach out to their members of Congress.

MACRA and QPP and APMs and MIPS- oh my! Yes, it’s time to dig in around the alphabet soup that replaced the SGR. The most important thing for you to know are the following two things:

  1. The ACS is working to develop APMs (Alternative Payment Models) for common procedures in conjunction with Brandeis. Again, stay tuned.
  2. The ACS will have a major education campaign for us around QPP (Quality Payment Project). If you want to see the resources that are being made available, please look here. There are four things that you can do to get ready for MIPS (Merit Based Incentive Payment System)- 2016 participation in PQRS, review your quality and resource use report (QRUR) from CMS, review the clinical practice improvement activities list when it’s released in November and choose 6 for 2017, and make sure your EMR is ONC certified/ review your meaningful use data. None of these things are terribly tricky, none are designed to be terribly time-consuming.  User-friendly videos, all of which provide information in digestible bites, will be available soon to help make this process as seamless as it can be for all of us.

I want to be clear- these are not the ONLY things that HPAG and the Advocacy and Policy Division are working on.  They’re simply the three things that struck me as the most pressing, most meaningful areas that the DC office and the ACS physician leaders are addressing.

And now…back to our regularly scheduled, non policy-wonk programming.

Advocacy for beginners

This week marked the LAST in-class session for our 4th year students and we focused their afternoon on health care policy related topics.  There were some definite heavy-hitters there, and I had the privilege of providing a more practical session on advocacy.  I’ll admit- I was pleasantly surprised at how many students signed up for it, and also pleasantly surprised at how many of them had previously participated in advocacy in some way.  I’m hopeful that a few more will based upon the tips I gave them (and the fact that it’s just not that hard to send an email to your Congressperson!).

Based upon our discussion on Wednesday (and some crowdsourcing on Twitter), I generated an advocacy pyramid.  As you work your way up, the level of commitment increases- and the number of those involved at that level decreases.





Advocacy Pyramid
Advocacy Pyramid

When I crowdsourced on Twitter, one of the biggest comments that I got was that people have NO idea where to start- understandably.  I’m hoping that both of these pyramids give you an idea of where to start (hint: purple!).  In terms of writing letters or calling a legislator’s office, several of our professional organizations make it very easy for you.

  • For my non-surgeon colleagues, the most ecumenical was to engage with healthcare issues is via the American Medical Association.  Their Legislative Action Center for their Physician Grassroots Network makes it quite easy.
  • For those in Academic Medicine, the AAMC has an excellent resource as well.  Note:  To use their member action center you do need a AAMC login.
  • And, dear surgeon readers, please check out the American College of Surgeons’ SurgeonsVoice resource.  It’s your roadmap for surgical advocacy.

If you want an easy way to try out contacting your Member of Congress and Senators, I recommend going to the SaveGME website.  I’m reasonably certain if you are reading my blog that you share the idea that we are about to be in big trouble with GME (residency slots) in the United States, particularly in 2016 when we will have more medical school graduates than residency slots.  The medical schools have expanded to accommodate the projected need for more physicians, but we’re stuck with the same number of residency positions we’ve had since the Balanced Budget Act went into effect- so we now have a pipeline problem.  Help us fix the pipeline!

If you’re inclined, I would also encourage you to set up an in-district meeting with your Congressperson or Senators when they are back home.  Yes, you can do this.  Tip for first timers:  Take a “wingman” (or wing woman) who has done this before.  It’s less scary that way.

And fairly, a shameless plug to the surgeons reading:  Attend the American College of Surgeons Leadership and Advocacy Summit in April.  It’s a wonderful opportunity to rub elbows with College leadership, you get spoon-fed the process for doing Hill visits, and your appointments all get made for you.  Most importantly, someone from your state will usually have done this before, so you have that wingman I alluded to above.  If you can’t go this year, I encourage you to consider it sometime for the connections and the opportunities.

An important principle to remember is that you are in this for the “long game,” so to speak, if you really want to engage. You will not get a win on one of your policy asks the first time that you walk into a Senators office.  What you can do, though, is develop long-term working relationships with staffers.  These relationships allow you to become their go-to expert when they have a question or issue that is within your area of expertise.  I’ve cultivated one of these relationships, and they’re honestly quite a bit of fun to have- and it makes office visits in those particular offices feel more like fun and less like work.

So, get involved.  Send a letter, make a call on an issue you’re passionate about.  It’s an easy thing to do, and it’s an important opportunity in our democracy.


(Note:  Lest you think I’m ignoring the money side of the equation, PAC membership and the like, I’m not…I’m saving that for another day.)


Vote early, vote often

It’s time for a bit of prosthelytizing from me, to those of you who are perhaps less politically engaged.

Many of you know that I’m a member of the SurgeonsPAC Board of Directors, a role in which I am honored to serve my profession.  The Health Policy and Advocacy team at the American College of Surgeons rolled out an exciting new program this year, Surgeons Voice; the goal of Surgeons Voice is to educate our members on how to be effective grassroots advocates for our profession and our patients.  Much like many non-profit organizations, one of the key principles is to make advocacy easy for our members- simply sign in, see what you need to act on, push a button and BAM!  Letter to your representative done.

We have also have created a tiered advocacy system, ranging from Beginner to Advanced, depending up on time, experience, and issue salience, with recommended activities for each of these levels.  While the Beginner moves are captured within the Surgeons Voice website (see my above description), what it excludes is the most basic thing that we can all do.


Yes, you read that right.  I’m reminding you to vote. I’m not telling you to donate to a candidate, or go do canvassing or literature drops for them, or anything that’s going to push you our of your comfort zone if you haven’t worked in this world before.  Vote, it’s as simple as that.

Here’s the thing.  It’s a midterm election, and even though there has been huge spending (see this Politico piece about outside spending in the Iowa race; thanks, Supreme Court, for that pesky Citizens United decision), midterm election turnout is historically 15-20% lower than in Presidential election years.  What that means to you, informed citizen, is that your vote is likely to count more- relatively speaking- in a midterm year.  In 2012, a Presidential election year, Representative Jim Matheson won by only 768 votes; in a midterm year, those results can change incredibly easily with fewer voters even heading to the polls.  And sometimes, just sometimes, surprise victories happen based upon better-than-predicted voter turnout among certain population segments- though I’ll confess that Clayton Williams did put his boot in his mouth more than once in ways that helped mobilize Ann Richards’ base.

I early voted on Friday.  I live in an electorally safe district in some weird ways- safe for the Republicans for the US legislature (Utah’s House districts give new meaning to “gerrymandered”- Matheson switched out of this district after it was drawn in 2010), safe for the Democrats for the Utah House and Senate.  It can be argued that my vote didn’t matter, and that may well be true if the renewal of the Zoo, Arts, and Parks program happens by a generous margin.  But…I voted.  It’s my responsibility as an advocate.  It’s my privilege as a citizen.  And most importantly, if I’m going to complain for the next couple of years about terrible political decisions, I best make sure I voted against those driving them.

Now, go.  Arrange your Tuesday so you can vote.  It’s the least you can do.



And now, an advocacy moment

Since last week I confessed my history as a political scientist, this week I’m going to have a policy and advocacy moment with you.

For at least the last decade, it seems that anytime I have had an interaction with one of my Senators or Representatives, one of the topics has been repeal of the Sustainable Growth Rate (SGR).  The very brief version of the SGR is that it is part of the formula used to calculate physician reimbursement for Medicare patients, that it is tied to the GDP, and that it has resulted in a series of steep cuts to physician payments from CMS.  Were it not for essentially annual pleas from physician groups, even steeper cuts would have occurred with the likely secondary effect of even fewer physicians being willing to care for Medicare patients.  While I used to think some of that was mere threat, I’ve learned from personal experience that it is not.  My father’s former internist, who is now retired from practice, was the only internist in the area taking new Medicare patients when my father first moved to SW Colorado.  While this is less of an issue for those in urban areas, it can obviously be a tremendous concern for Medicare patients who live in rural and frontier areas.

For the last several years, we’ve all discussed the tendency of Congress to “kick the can” down the road with respect to the SGR.  What that means is that while a series of one-time patches have been passed to prevent 20% or greater cuts in CMS payments, no durable solution has been put into place.  A bipartisan agreement that has broad support from the medical community was reached on February 6; this agreement would do away with the highly flawed SGR and would reform how physician payment is managed by CMS.  However, Congress actually needs to pass the related bills and get them to Obama’s desk for signature.

How can you help with this process?  Simple.  Contact your Representative and your Senators.  I promise that their offices keep track of what they hear about pieces of legislation, and I also promise there are plenty of groups in opposition to the bill because of the $150 billion price tag attached to it since they stand to lose access to that money.  Our voices need to be heard.  For the surgeons, you can use the ACS Hotline (1-877-996-4464), enter your zip code, and they’ll connect you to the appropriate offices.  If you’re not a surgeon, please identify your Senators and Representative and get in touch with their offices ASAP.  If you are having trouble figuring out who represents you, inbox me or leave a comment here and I will help you figure it out.  This is that important!

Your message when you call is simple- identify yourself as a constituent, and ask your Representative and Senators to Sponsor HR4015/ S2000, and to help it come to a vote before April 1 (which is when the next round of SGR cuts is due to go into effect).  This isn’t just about insuring fair pay for Medicare providers- it’s also about insuring access to care for patients who rely on their Medicare benefits.

3 phone calls, 10 minutes or less, and you can make a difference.  Please reach out.


Hill Visits, April 23, with our fabulous Utah delegation
Hill Visits, April 2013, with our fabulous Utah delegation


Reference:  For a more complete introduction to Medicare and the SGR, this resource from the American Medical Association is a terrific primer.