Surgical Subspecialties Escape Medicare Cuts and Protect Patients

Imagine a single organization that is composed of: The American Academy of Ophthalmology, American Association of Neurological Surgeons, American College of Osteopathic Surgeons, American College of Surgeons, American Society for Surgery of the Hand, American Society of Colon and Rectal Surgeons, American Society of Plastic Surgeons, Congress of Neurological Surgeons, Society for Vascular Surgery, Society of American Gastrointestinal and Endoscopic Surgeons, The American Society of Breast Surgeons, and The Society of Thoracic Surgeons. Those are 12 different national organizations that have all united for a single goal, and one would be hard-pressed to think of a surgical specialty that is not represented. It is nothing short of a revolutionary association of some of America’s brightest physicians. These 12 organizations have voiced their support in promoting access to surgical care by forming the Surgical Care Coalition, which successfully halted Medicare cuts on December 22, 2020.  

To better understand why the Surgical Care Coalition was formed, it is imperative to understand the role of Congress in enforcing and supporting an infrastructure that allows patients to have access to surgical care. Congress is responsible for legislation that affects the Centers for Medicare and Medicaid Services (CMS), which is responsible for the devising reimbursement rates for Medicare and Medicaid. Their influence is large because Medicare and Medicaid support 25% of Americans, and 33% of total healthcare expenditures in America. However, the CMS decided to make drastic changes by planning to adjust the reimbursement conversion factor for several surgical specialties, resulting in up to a 9% cut in Medicare payments, beginning on January 1, 2021. Conversion factors are multiplied with relative value units (RVUs), which determine the compensation for a particular clinical intervention or service. 

These cuts in the conversion factor are significant because they go beyond affecting revenue streams. Firstly, they affect many different disciplines of surgery, and all of them simultaneously, including specialists such such as ophthalmologists, general surgeons, neurosurgeons, vascular surgeons, cardiothoracic surgeons, and plastic surgeons. Secondly, they stifle the operating capacity of surgical providers to support the care of Medicare patients, potentially contriving surgeons to reduce Medicare patient intake so that surgeons can maintain their practices. Surgeons would become more reluctant to accept Medicare patients if these cuts were enacted because surgeons would have lower reimbursements from those Medicare patients, and would consequently have to cater their practices to more non-Medicare patients in order to cover their operating expenses. This would severely affect access to quality to surgical care in Medicare patients. Thirdly, they make surgeons consider cost-saving mechanisms such as laying off support staff, nurses, and administrators. Finally, they hinder innovation because surgeons will have fewer resources to support innovative projects that may improve clinical care. Decreases in Medicare reimbursements would strain revenue sources of surgeons, and prevent them from investing in newer technology that could be beneficial to patients and increase efficiency. The combination of these factors suggest how the initially proposed Medicare cuts could have been severely catastrophic for surgical patients across a broad spectrum of interventions and specialties if the Surgical Care Coalition did not oppose it. 

This is particularly problematic because it happened during the Covid-19 pandemic, and most of these surgical specialists have been tasked with caring for Covid-19 patients. For instance, for some critically ill Covid-19 patients, they are shifted to extracorporeal membrane oxygenation (ECMO), which is a technique of providing cardiac and respiratory support to a patient and is housed in the specialty of cardiothoracic surgery. Additionally, many hospitals were forced to reduce their number of elective procedures during Covid-19, and the surgical staff who were originally involved with the elective procedures joined the frontlines against Covid-19. It is highly contentious to introduce reimbursement cuts to physicians who worked in frontline care during a pandemic, and adding little opportunity to increase reimbursements in the future. 

This prompted the birth of the Surgical Care Coalition, which simply formalizes a relationship that had already existed between different surgical specialties. The Surgical Care Coalition was successful in delaying the Medicare cuts till 2022. However, there is a significant desire to identify viable avenues to promote access to surgical care beyond these two calendar years. This was accomplished with Holding Providers Harmless From Medicare Cuts During Covid-19 Act of 2020, which was championed by Representatives Ami Bera, MD (CA-7) and Larry Bucshon, MD (IN-8) and had bipartisan support from 54 co-sponsors, and 229 Members of the House. The formalization of organizations, such as the Surgical Care Coalition, advances clinical care towards comprehensive and integrated systems that extend beyond an individual condition or patient. Other medical specialties should take note of the Surgical Care Coaltion’s success and attempt to recapitulate it in their own specialties through similar multidisciplinary efforts. Since clinical care is becoming more interdisciplinary, it is only rational to have policy and policy advocacy also become more interdisciplinary. 

Safeguarding surgical care is a phenomenon that receives significantly less fanfare than safeguarding other forms of clinical care. However, it is equally important to ensure patients have access to quality surgical care in the aftermath of Covid-19 as it is to ensure that patients have access to other medical specialties because our sickest often require surgical care. Therefore, as policymakers look to better our future healthcare system, whose flaws were exacerbated in 2020, it is imperative that access to surgical care ranks highly in their agendas. 

Ashwin Palaniappan is a senior at Brown, attending medical school in the fall. He can be reached at ashwin_palaniappan@brown.edu.