Policy Experts Parse Implications of Health Care Reform

SAN FRANCISCO – Societal trends will trump health reform in changing the health care system, and surgeons need to do their part to decrease costs, leaders in the American College of Surgeons said at their annual clinical congress.

"Change is happening in spite of, alongside, and with the Affordable Care Act [ACA]," said Thomas Ricketts, Ph.D., codirector of the American College of Surgeons Health Policy Research Institute. Change is being driven as much as or more by the economy along with institutional and professional decisions, he said.

Those forces are shifting the health care system from one that is dominated by independent physicians and surgeons to one in which physicians will be employees. Health insurers are linking up with clinician groups. Instead of community-based hospitals responsive to local needs, institutions are aggregating in large, geographically spread "empires" that are learning how to manage themselves, said Dr. Ricketts, professor of health policy and management at the University of North Carolina at Chapel Hill.

The pace of mergers accelerated after passage of the ACA in March 2010. In the first two quarters of 2011 there were 139 mergers or acquisitions involving hospitals, compared with 37-82 in each of the years from 2001 to 2010, he said.

The ACA will make health coverage accessible to an estimated 32 million currently uninsured Americans. Seven in 10 hospitals and health systems in the United States plan to hire more physicians in the next 1-3 years, but it’s unclear whether there will be enough physicians. "It’s a huge problem," Dr. Ricketts said.

Physicians and patients should brace themselves for what he called "simple complexity" in the evolving health system, which will define the individual roles of providers with specificity, yet add complexity as system structures evolve.

Major provisions of the ACA will roll out over time, but many of the provisions of particular concern to surgeons kick in by 2014, Dr. Don E. Detmer said in a separate presentation during the same session. Enactment began with 13 components in 2010 involving payment reform, workforce and quality-of-care improvements, access to care, and new insurance rules. Eight major provisions in 2011 affected physician quality reporting, new approaches to payment and delivery of care, and more, said Dr. Detmer, medical director of the ACS Division of Advocacy and Health Policy.

In 2012, four provisions kick in that involve reduced payments for preventable hospital readmissions, launch of Accountable Care Organizations, higher Medicare payments to hospitals with high-quality and outcomes data, and required reporting of data on health disparities.

Five major provisions starting in 2013 include bundled payments for episodes of postacute care, limits on flexible spending accounts, increased payroll taxes for Medicare, expansion of preventive services in Medicaid, and electronic simplification of some administrative functions.

The top four of nine provisions that start in 2014 include creation of an essential benefits package for insurers to offer, the start of insurance exchanges through employers or states to offer insurance to people who have no coverage, a requirement for uninsured individuals to buy coverage or pay a penalty, and creation of an independent payment advisory board to identify potentially wasteful spending in Medicare.

As enacted, the ACA is unlikely to produce sufficient reforms to significantly alter the curve of ever-increasing costs through overall system performance, "but the ACA plus physician payment reforms just might," predicted Dr. Detmer, professor emeritus at the University of Virginia, Charlottesville.

Another player besides the ACA could have had a drastic effect – the Congressional Joint Select Committee on Deficit Reduction (also called the Super Committee) was charged with decreasing federal budget deficits by $1.2 trillion between 2012 and 2021. They failed to agree on a plan, so, that will likely trigger massive, widespread cuts in federal spending starting in January 2013.

Policy-driven changes in health care make many physicians nervous, but any resulting changes are "probably not as scary as what we’ve got now," Dr. Detmer said.

A separate federal commission on government spending, known as the Debt Commission, has recommended a number of reductions in health care spending, including cutting $54 billion from graduate and indirect medical education between 2012 and 2020, Dr. George F. Sheldon said in a separate presentation during the session. Fifteen new U.S. medical schools currently are planned with no federal support, which may help supply the physicians and surgeons needed to meet growing demand for care, but the schools alone will not be sufficient, said Dr. Sheldon, codirector of the ACS Health Policy Research Institute.

Of the 26,769 active general surgeons in the United States, 42% are aged 55 years or older, 2008 data show. The number of active general surgeons decreased by 2% between 1996 and 2006, especially in rural areas, other studies report.

The regionalization of health systems offers an opportunity for different models of surgical care, he suggested. Surgeons and high-technology equipment may locate more in regional centers than individual practices.

Government programs could do more to increase the supply of surgeons, added Dr. Sheldon, professor of surgery at the University of North Carolina at Chapel Hill. The National Health Service Corps doesn’t include surgeons, "but it would be great if they did," he said.

Creating new medical schools – and somehow finding the residency programs to train the extra graduates – is a good long-term plan, but it doesn’t solve immediate workforce shortages, said Dr. Andrew L. Warshaw, chair of the ACS Health Policy Advisory Group. "If we have shortages now, it will be worse" as the ACA is implemented, he said in a presentation during the session. He noted that such shortages occurred in Massachusetts after the state adopted universal health care coverage.

Greater use of mid-level providers may help extend physicians’ reach, and regionalization models can either put more physicians where they’re needed or bring patients to physicians’ locations, he suggested.

But physicians need to tackle costs of health care, added Dr. Warshaw, of Harvard Medical School, Boston. If any solutions include a fix of the Sustainable Growth Rate (SGR) formula as requested by physicians, $1.6 trillion instead of $1.2 trillion would have to be cut from the federal deficit – cuts that could come from other parts of health care.

"What can surgeons do?" Dr. Warshaw said. "Every person in this room needs to do something, somewhere, somehow within your own practice to figure out what’s the right kind of care to give your patients. There’s good evidence that that can go a long way toward paying down the SGR."

If postoperative complications cost an average of $10,000, preventing just one postoperative complication per day at every U.S. hospital would reduce costs by $125-$250 billion over 10 years, he estimated.

Surgeons also need to figure out optimal care for patients and demand that other specialties do the same. One study at Massachusetts General Hospital found that physicians ordered between 1 and 30 CAT scans for patients seen in the emergency department for head trauma. Such a wide range in practices is "wrong," he said. "It’s our job to figure this out." Medical liability reform potentially could save another $62 billion in health care costs over 10 years, he added.

"I don’t think we can count on the ACA to reduce costs. We have to do a lot more," Dr. Warshaw said. "There’s a huge amount going on, and it’s way ahead of the Affordable Care Act in many ways."

Dr. Detmer has consulted for CS Placement. Dr. Ricketts, Dr. Sheldon, and Dr. Warshaw said that they had no financial conflicts. ☐

SAN FRANCISCO – Societal trends will trump health reform in changing the health care system, and surgeons need to do their part to decrease costs, leaders in the American College of Surgeons said at their annual clinical congress.

"Change is happening in spite of, alongside, and with the Affordable Care Act [ACA]," said Thomas Ricketts, Ph.D., codirector of the American College of Surgeons Health Policy Research Institute. Change is being driven as much as or more by the economy along with institutional and professional decisions, he said.

Those forces are shifting the health care system from one that is dominated by independent physicians and surgeons to one in which physicians will be employees. Health insurers are linking up with clinician groups. Instead of community-based hospitals responsive to local needs, institutions are aggregating in large, geographically spread "empires" that are learning how to manage themselves, said Dr. Ricketts, professor of health policy and management at the University of North Carolina at Chapel Hill.

The pace of mergers accelerated after passage of the ACA in March 2010. In the first two quarters of 2011 there were 139 mergers or acquisitions involving hospitals, compared with 37-82 in each of the years from 2001 to 2010, he said.

The ACA will make health coverage accessible to an estimated 32 million currently uninsured Americans. Seven in 10 hospitals and health systems in the United States plan to hire more physicians in the next 1-3 years, but it’s unclear whether there will be enough physicians. "It’s a huge problem," Dr. Ricketts said.

Physicians and patients should brace themselves for what he called "simple complexity" in the evolving health system, which will define the individual roles of providers with specificity, yet add complexity as system structures evolve.

Major provisions of the ACA will roll out over time, but many of the provisions of particular concern to surgeons kick in by 2014, Dr. Don E. Detmer said in a separate presentation during the same session. Enactment began with 13 components in 2010 involving payment reform, workforce and quality-of-care improvements, access to care, and new insurance rules. Eight major provisions in 2011 affected physician quality reporting, new approaches to payment and delivery of care, and more, said Dr. Detmer, medical director of the ACS Division of Advocacy and Health Policy.

In 2012, four provisions kick in that involve reduced payments for preventable hospital readmissions, launch of Accountable Care Organizations, higher Medicare payments to hospitals with high-quality and outcomes data, and required reporting of data on health disparities.

Five major provisions starting in 2013 include bundled payments for episodes of postacute care, limits on flexible spending accounts, increased payroll taxes for Medicare, expansion of preventive services in Medicaid, and electronic simplification of some administrative functions.

The top four of nine provisions that start in 2014 include creation of an essential benefits package for insurers to offer, the start of insurance exchanges through employers or states to offer insurance to people who have no coverage, a requirement for uninsured individuals to buy coverage or pay a penalty, and creation of an independent payment advisory board to identify potentially wasteful spending in Medicare.

As enacted, the ACA is unlikely to produce sufficient reforms to significantly alter the curve of ever-increasing costs through overall system performance, "but the ACA plus physician payment reforms just might," predicted Dr. Detmer, professor emeritus at the University of Virginia, Charlottesville.

Another player besides the ACA could have had a drastic effect – the Congressional Joint Select Committee on Deficit Reduction (also called the Super Committee) was charged with decreasing federal budget deficits by $1.2 trillion between 2012 and 2021. They failed to agree on a plan, so, that will likely trigger massive, widespread cuts in federal spending starting in January 2013.

Policy-driven changes in health care make many physicians nervous, but any resulting changes are "probably not as scary as what we’ve got now," Dr. Detmer said.

A separate federal commission on government spending, known as the Debt Commission, has recommended a number of reductions in health care spending, including cutting $54 billion from graduate and indirect medical education between 2012 and 2020, Dr. George F. Sheldon said in a separate presentation during the session. Fifteen new U.S. medical schools currently are planned with no federal support, which may help supply the physicians and surgeons needed to meet growing demand for care, but the schools alone will not be sufficient, said Dr. Sheldon, codirector of the ACS Health Policy Research Institute.

Of the 26,769 active general surgeons in the United States, 42% are aged 55 years or older, 2008 data show. The number of active general surgeons decreased by 2% between 1996 and 2006, especially in rural areas, other studies report.

The regionalization of health systems offers an opportunity for different models of surgical care, he suggested. Surgeons and high-technology equipment may locate more in regional centers than individual practices.

Government programs could do more to increase the supply of surgeons, added Dr. Sheldon, professor of surgery at the University of North Carolina at Chapel Hill. The National Health Service Corps doesn’t include surgeons, "but it would be great if they did," he said.

Creating new medical schools – and somehow finding the residency programs to train the extra graduates – is a good long-term plan, but it doesn’t solve immediate workforce shortages, said Dr. Andrew L. Warshaw, chair of the ACS Health Policy Advisory Group. "If we have shortages now, it will be worse" as the ACA is implemented, he said in a presentation during the session. He noted that such shortages occurred in Massachusetts after the state adopted universal health care coverage.

Greater use of mid-level providers may help extend physicians’ reach, and regionalization models can either put more physicians where they’re needed or bring patients to physicians’ locations, he suggested.

But physicians need to tackle costs of health care, added Dr. Warshaw, of Harvard Medical School, Boston. If any solutions include a fix of the Sustainable Growth Rate (SGR) formula as requested by physicians, $1.6 trillion instead of $1.2 trillion would have to be cut from the federal deficit – cuts that could come from other parts of health care.

"What can surgeons do?" Dr. Warshaw said. "Every person in this room needs to do something, somewhere, somehow within your own practice to figure out what’s the right kind of care to give your patients. There’s good evidence that that can go a long way toward paying down the SGR."

If postoperative complications cost an average of $10,000, preventing just one postoperative complication per day at every U.S. hospital would reduce costs by $125-$250 billion over 10 years, he estimated.

Surgeons also need to figure out optimal care for patients and demand that other specialties do the same. One study at Massachusetts General Hospital found that physicians ordered between 1 and 30 CAT scans for patients seen in the emergency department for head trauma. Such a wide range in practices is "wrong," he said. "It’s our job to figure this out." Medical liability reform potentially could save another $62 billion in health care costs over 10 years, he added.

"I don’t think we can count on the ACA to reduce costs. We have to do a lot more," Dr. Warshaw said. "There’s a huge amount going on, and it’s way ahead of the Affordable Care Act in many ways."

Dr. Detmer has consulted for CS Placement. Dr. Ricketts, Dr. Sheldon, and Dr. Warshaw said that they had no financial conflicts. ☐

SAN FRANCISCO – Societal trends will trump health reform in changing the health care system, and surgeons need to do their part to decrease costs, leaders in the American College of Surgeons said at their annual clinical congress.

"Change is happening in spite of, alongside, and with the Affordable Care Act [ACA]," said Thomas Ricketts, Ph.D., codirector of the American College of Surgeons Health Policy Research Institute. Change is being driven as much as or more by the economy along with institutional and professional decisions, he said.

Those forces are shifting the health care system from one that is dominated by independent physicians and surgeons to one in which physicians will be employees. Health insurers are linking up with clinician groups. Instead of community-based hospitals responsive to local needs, institutions are aggregating in large, geographically spread "empires" that are learning how to manage themselves, said Dr. Ricketts, professor of health policy and management at the University of North Carolina at Chapel Hill.

The pace of mergers accelerated after passage of the ACA in March 2010. In the first two quarters of 2011 there were 139 mergers or acquisitions involving hospitals, compared with 37-82 in each of the years from 2001 to 2010, he said.

The ACA will make health coverage accessible to an estimated 32 million currently uninsured Americans. Seven in 10 hospitals and health systems in the United States plan to hire more physicians in the next 1-3 years, but it’s unclear whether there will be enough physicians. "It’s a huge problem," Dr. Ricketts said.

Physicians and patients should brace themselves for what he called "simple complexity" in the evolving health system, which will define the individual roles of providers with specificity, yet add complexity as system structures evolve.

Major provisions of the ACA will roll out over time, but many of the provisions of particular concern to surgeons kick in by 2014, Dr. Don E. Detmer said in a separate presentation during the same session. Enactment began with 13 components in 2010 involving payment reform, workforce and quality-of-care improvements, access to care, and new insurance rules. Eight major provisions in 2011 affected physician quality reporting, new approaches to payment and delivery of care, and more, said Dr. Detmer, medical director of the ACS Division of Advocacy and Health Policy.

In 2012, four provisions kick in that involve reduced payments for preventable hospital readmissions, launch of Accountable Care Organizations, higher Medicare payments to hospitals with high-quality and outcomes data, and required reporting of data on health disparities.

Five major provisions starting in 2013 include bundled payments for episodes of postacute care, limits on flexible spending accounts, increased payroll taxes for Medicare, expansion of preventive services in Medicaid, and electronic simplification of some administrative functions.

The top four of nine provisions that start in 2014 include creation of an essential benefits package for insurers to offer, the start of insurance exchanges through employers or states to offer insurance to people who have no coverage, a requirement for uninsured individuals to buy coverage or pay a penalty, and creation of an independent payment advisory board to identify potentially wasteful spending in Medicare.

As enacted, the ACA is unlikely to produce sufficient reforms to significantly alter the curve of ever-increasing costs through overall system performance, "but the ACA plus physician payment reforms just might," predicted Dr. Detmer, professor emeritus at the University of Virginia, Charlottesville.

Another player besides the ACA could have had a drastic effect – the Congressional Joint Select Committee on Deficit Reduction (also called the Super Committee) was charged with decreasing federal budget deficits by $1.2 trillion between 2012 and 2021. They failed to agree on a plan, so, that will likely trigger massive, widespread cuts in federal spending starting in January 2013.

Policy-driven changes in health care make many physicians nervous, but any resulting changes are "probably not as scary as what we’ve got now," Dr. Detmer said.

A separate federal commission on government spending, known as the Debt Commission, has recommended a number of reductions in health care spending, including cutting $54 billion from graduate and indirect medical education between 2012 and 2020, Dr. George F. Sheldon said in a separate presentation during the session. Fifteen new U.S. medical schools currently are planned with no federal support, which may help supply the physicians and surgeons needed to meet growing demand for care, but the schools alone will not be sufficient, said Dr. Sheldon, codirector of the ACS Health Policy Research Institute.

Of the 26,769 active general surgeons in the United States, 42% are aged 55 years or older, 2008 data show. The number of active general surgeons decreased by 2% between 1996 and 2006, especially in rural areas, other studies report.

The regionalization of health systems offers an opportunity for different models of surgical care, he suggested. Surgeons and high-technology equipment may locate more in regional centers than individual practices.

Government programs could do more to increase the supply of surgeons, added Dr. Sheldon, professor of surgery at the University of North Carolina at Chapel Hill. The National Health Service Corps doesn’t include surgeons, "but it would be great if they did," he said.

Creating new medical schools – and somehow finding the residency programs to train the extra graduates – is a good long-term plan, but it doesn’t solve immediate workforce shortages, said Dr. Andrew L. Warshaw, chair of the ACS Health Policy Advisory Group. "If we have shortages now, it will be worse" as the ACA is implemented, he said in a presentation during the session. He noted that such shortages occurred in Massachusetts after the state adopted universal health care coverage.

Greater use of mid-level providers may help extend physicians’ reach, and regionalization models can either put more physicians where they’re needed or bring patients to physicians’ locations, he suggested.

But physicians need to tackle costs of health care, added Dr. Warshaw, of Harvard Medical School, Boston. If any solutions include a fix of the Sustainable Growth Rate (SGR) formula as requested by physicians, $1.6 trillion instead of $1.2 trillion would have to be cut from the federal deficit – cuts that could come from other parts of health care.

"What can surgeons do?" Dr. Warshaw said. "Every person in this room needs to do something, somewhere, somehow within your own practice to figure out what’s the right kind of care to give your patients. There’s good evidence that that can go a long way toward paying down the SGR."

If postoperative complications cost an average of $10,000, preventing just one postoperative complication per day at every U.S. hospital would reduce costs by $125-$250 billion over 10 years, he estimated.

Surgeons also need to figure out optimal care for patients and demand that other specialties do the same. One study at Massachusetts General Hospital found that physicians ordered between 1 and 30 CAT scans for patients seen in the emergency department for head trauma. Such a wide range in practices is "wrong," he said. "It’s our job to figure this out." Medical liability reform potentially could save another $62 billion in health care costs over 10 years, he added.

"I don’t think we can count on the ACA to reduce costs. We have to do a lot more," Dr. Warshaw said. "There’s a huge amount going on, and it’s way ahead of the Affordable Care Act in many ways."

Dr. Detmer has consulted for CS Placement. Dr. Ricketts, Dr. Sheldon, and Dr. Warshaw said that they had no financial conflicts. ☐