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Minimally invasive colon surgery: Managing conversions
LAS VEGAS – Minimally invasive colon surgery has many advantages over an open procedure with respect to complications and patient recovery, but as surgeons are well aware, sometimes conversion cannot and should not be avoided. “It’s going to happen, and if you’re not converting any of your patients, then you’re probably not being aggressive enough,” said Bradley R. Davis, MD, FACS, at a talk he gave on the topic at the Annual Minimally Invasive Surgery Symposium (MISS) 2018 by Global Academy for Medical Education.
Dr. Davis discussed some of the most common reasons for conversion to open surgery and strategies to try to reduce the incidence. He is the chief of general surgery and the chief of rectal and rectal surgery at Carolinas Medical Center, Charlotte, N.C.
A 2017 survey of 41,417 left hemicolectomy and sigmoidectomy procedures revealed that 63.4% were attempted laparoscopically, and the rate of conversion to an open procedure was 13.4% (JSLS. 2017 Jul-Sep;21[3]:e2017.00036). “I think that if your conversation rate is between 5% and 15%, [it’s] perfectly acceptable,” said Dr. Davis.
He suggested that surgeons should be willing to consider an increasing number of cases for minimally invasive surgery, despite the risk of conversion. By taking some precautions and being aware of which cases are most likely to lead to conversion, surgeons can potentially reduce the conversion rate – or at least lessen the effects it can have on patients and on costs.
Dr. Davis started with a discussion of the surgeon factors that can affect conversion rates. Medial and lateral approaches seem to have similar learning curves. “You’ve got to just stick to one approach. There’s not going to be any difference in terms of [frequency of] conversions,” said Dr. Davis.
Vascular pedicle ligation is the easiest approach, he said. Flexure mobilizations can be challenging, but they aren’t necessarily easier in open surgery. “If you’re struggling to mobilize the flexure, that may be the time to keep struggling because often when we go to open surgery [it doesn’t] get any easier,” said Dr. Davis.
The transverse colon mesentery is most difficult. “If you’re early in your learning curve, that’s something that’s going to be a little more difficult. The learning curve is between 50 and 60 cases,” said Dr. Davis.
Adhesions are the most common cause of conversions, but Dr. Davis said he generally starts with an attempt at laparoscopy. When he has a questionable case, he notifies the operating room staff that it should be prepared for a conversion so they don’t open a lot of disposables.
Other causes of conversion include pedicle or solid organ bleeding, hollow viscus injuries, and anastomotic complications. “As you get more up on your learning curve, you’ll be more comfortable in managing a hole in the bowel laparoscopically. ... Often you can manage those through your extraction site, so you can temporize that with a stitch and then bring it out and look at it,” said Dr. Davis.
Air leaks while doing an anastomosis on the sigmoid can also lead to conversion. “If you have a Pfannenstiel incision, you can do it through the Pfannenstiel, but if you have no incision, you are probably going to want to do some kind of incision to take a peek at that,” said Dr. Davis.
In neoplasms, conversions are common to ensure negative margins, which can’t always be accomplished laparoscopically.
Severe diverticulitis is another case that can mean a conversion, but hand-assisted techniques can be employed to avoid conversion. In severe diverticulitis, ureteral catheters can be helpful. “We identified a lower incidence of ureteral injury [with the use of ureteral catheters] in diverticulitis and T4 cancers. If you have a big phlegmon or a big cancer, I would definitely consider ureteral catheters,” said Dr. Davis. He pointed out that an inability to pinpoint the ureter is daunting in these types of cases. “That’s another thing to plan on if you know you’re going into these tough cases – trying to maximize your chances of not having a conversion by giving yourself the best possible tools to and the best visualization possible,” he added.
Obesity and inflammatory bowel disease are other conversion risk factors, as is performing a left hemicolectomy versus a sigmoidectomy. “As you plan your surgery, if you know you’ve got an obese patient with bad diverticulitis, this might be someone you would schedule as a laparoscopic versus open, with minimum disposable equipment in the room, knowing that, if it’s just not going to happen, then you need to open,” said Dr. Davis.
Technical factors that can contribute to conversion include failures of staplers, clips, and energy devices. When bleeding occurs as a result of an energy device, he doesn’t repeat its use. “If the energy has failed, I go right to an endoloop,” said Dr. Davis.
Bleeding in general needs to be controlled quickly or converted to open. “If you can’t get control of bleeding, that’s when you want to make a quick decision to open. You don’t want to lose two liters of blood trying to be fancy,” said Dr. Davis.
“Cautery injuries will happen, and it doesn’t take much to cause a full-thickness injury. It’s important to address it immediately, rather than move on, since it can be difficult to find after you’ve moved on to something else. Serosal injuries should also be dealt with right away,” he said.
A staple misfire can sometimes be repaired laparoscopically, but if it can’t, the patient should be opened up. “It’s just not worth the leak to prevent an incision,” said Dr. Davis.
Finally, body mass index is a strong predictor of conversion because of the difficulties it presents. “These aren’t cases that are fun to do open, either, but it’s going to be something that we’ll have to get better and better at as we see more of these patients,” said Dr. Davis.
Global Academy for Medical Education and this news organization are owned by the same parent company.
LAS VEGAS – Minimally invasive colon surgery has many advantages over an open procedure with respect to complications and patient recovery, but as surgeons are well aware, sometimes conversion cannot and should not be avoided. “It’s going to happen, and if you’re not converting any of your patients, then you’re probably not being aggressive enough,” said Bradley R. Davis, MD, FACS, at a talk he gave on the topic at the Annual Minimally Invasive Surgery Symposium (MISS) 2018 by Global Academy for Medical Education.
Dr. Davis discussed some of the most common reasons for conversion to open surgery and strategies to try to reduce the incidence. He is the chief of general surgery and the chief of rectal and rectal surgery at Carolinas Medical Center, Charlotte, N.C.
A 2017 survey of 41,417 left hemicolectomy and sigmoidectomy procedures revealed that 63.4% were attempted laparoscopically, and the rate of conversion to an open procedure was 13.4% (JSLS. 2017 Jul-Sep;21[3]:e2017.00036). “I think that if your conversation rate is between 5% and 15%, [it’s] perfectly acceptable,” said Dr. Davis.
He suggested that surgeons should be willing to consider an increasing number of cases for minimally invasive surgery, despite the risk of conversion. By taking some precautions and being aware of which cases are most likely to lead to conversion, surgeons can potentially reduce the conversion rate – or at least lessen the effects it can have on patients and on costs.
Dr. Davis started with a discussion of the surgeon factors that can affect conversion rates. Medial and lateral approaches seem to have similar learning curves. “You’ve got to just stick to one approach. There’s not going to be any difference in terms of [frequency of] conversions,” said Dr. Davis.
Vascular pedicle ligation is the easiest approach, he said. Flexure mobilizations can be challenging, but they aren’t necessarily easier in open surgery. “If you’re struggling to mobilize the flexure, that may be the time to keep struggling because often when we go to open surgery [it doesn’t] get any easier,” said Dr. Davis.
The transverse colon mesentery is most difficult. “If you’re early in your learning curve, that’s something that’s going to be a little more difficult. The learning curve is between 50 and 60 cases,” said Dr. Davis.
Adhesions are the most common cause of conversions, but Dr. Davis said he generally starts with an attempt at laparoscopy. When he has a questionable case, he notifies the operating room staff that it should be prepared for a conversion so they don’t open a lot of disposables.
Other causes of conversion include pedicle or solid organ bleeding, hollow viscus injuries, and anastomotic complications. “As you get more up on your learning curve, you’ll be more comfortable in managing a hole in the bowel laparoscopically. ... Often you can manage those through your extraction site, so you can temporize that with a stitch and then bring it out and look at it,” said Dr. Davis.
Air leaks while doing an anastomosis on the sigmoid can also lead to conversion. “If you have a Pfannenstiel incision, you can do it through the Pfannenstiel, but if you have no incision, you are probably going to want to do some kind of incision to take a peek at that,” said Dr. Davis.
In neoplasms, conversions are common to ensure negative margins, which can’t always be accomplished laparoscopically.
Severe diverticulitis is another case that can mean a conversion, but hand-assisted techniques can be employed to avoid conversion. In severe diverticulitis, ureteral catheters can be helpful. “We identified a lower incidence of ureteral injury [with the use of ureteral catheters] in diverticulitis and T4 cancers. If you have a big phlegmon or a big cancer, I would definitely consider ureteral catheters,” said Dr. Davis. He pointed out that an inability to pinpoint the ureter is daunting in these types of cases. “That’s another thing to plan on if you know you’re going into these tough cases – trying to maximize your chances of not having a conversion by giving yourself the best possible tools to and the best visualization possible,” he added.
Obesity and inflammatory bowel disease are other conversion risk factors, as is performing a left hemicolectomy versus a sigmoidectomy. “As you plan your surgery, if you know you’ve got an obese patient with bad diverticulitis, this might be someone you would schedule as a laparoscopic versus open, with minimum disposable equipment in the room, knowing that, if it’s just not going to happen, then you need to open,” said Dr. Davis.
Technical factors that can contribute to conversion include failures of staplers, clips, and energy devices. When bleeding occurs as a result of an energy device, he doesn’t repeat its use. “If the energy has failed, I go right to an endoloop,” said Dr. Davis.
Bleeding in general needs to be controlled quickly or converted to open. “If you can’t get control of bleeding, that’s when you want to make a quick decision to open. You don’t want to lose two liters of blood trying to be fancy,” said Dr. Davis.
“Cautery injuries will happen, and it doesn’t take much to cause a full-thickness injury. It’s important to address it immediately, rather than move on, since it can be difficult to find after you’ve moved on to something else. Serosal injuries should also be dealt with right away,” he said.
A staple misfire can sometimes be repaired laparoscopically, but if it can’t, the patient should be opened up. “It’s just not worth the leak to prevent an incision,” said Dr. Davis.
Finally, body mass index is a strong predictor of conversion because of the difficulties it presents. “These aren’t cases that are fun to do open, either, but it’s going to be something that we’ll have to get better and better at as we see more of these patients,” said Dr. Davis.
Global Academy for Medical Education and this news organization are owned by the same parent company.
LAS VEGAS – Minimally invasive colon surgery has many advantages over an open procedure with respect to complications and patient recovery, but as surgeons are well aware, sometimes conversion cannot and should not be avoided. “It’s going to happen, and if you’re not converting any of your patients, then you’re probably not being aggressive enough,” said Bradley R. Davis, MD, FACS, at a talk he gave on the topic at the Annual Minimally Invasive Surgery Symposium (MISS) 2018 by Global Academy for Medical Education.
Dr. Davis discussed some of the most common reasons for conversion to open surgery and strategies to try to reduce the incidence. He is the chief of general surgery and the chief of rectal and rectal surgery at Carolinas Medical Center, Charlotte, N.C.
A 2017 survey of 41,417 left hemicolectomy and sigmoidectomy procedures revealed that 63.4% were attempted laparoscopically, and the rate of conversion to an open procedure was 13.4% (JSLS. 2017 Jul-Sep;21[3]:e2017.00036). “I think that if your conversation rate is between 5% and 15%, [it’s] perfectly acceptable,” said Dr. Davis.
He suggested that surgeons should be willing to consider an increasing number of cases for minimally invasive surgery, despite the risk of conversion. By taking some precautions and being aware of which cases are most likely to lead to conversion, surgeons can potentially reduce the conversion rate – or at least lessen the effects it can have on patients and on costs.
Dr. Davis started with a discussion of the surgeon factors that can affect conversion rates. Medial and lateral approaches seem to have similar learning curves. “You’ve got to just stick to one approach. There’s not going to be any difference in terms of [frequency of] conversions,” said Dr. Davis.
Vascular pedicle ligation is the easiest approach, he said. Flexure mobilizations can be challenging, but they aren’t necessarily easier in open surgery. “If you’re struggling to mobilize the flexure, that may be the time to keep struggling because often when we go to open surgery [it doesn’t] get any easier,” said Dr. Davis.
The transverse colon mesentery is most difficult. “If you’re early in your learning curve, that’s something that’s going to be a little more difficult. The learning curve is between 50 and 60 cases,” said Dr. Davis.
Adhesions are the most common cause of conversions, but Dr. Davis said he generally starts with an attempt at laparoscopy. When he has a questionable case, he notifies the operating room staff that it should be prepared for a conversion so they don’t open a lot of disposables.
Other causes of conversion include pedicle or solid organ bleeding, hollow viscus injuries, and anastomotic complications. “As you get more up on your learning curve, you’ll be more comfortable in managing a hole in the bowel laparoscopically. ... Often you can manage those through your extraction site, so you can temporize that with a stitch and then bring it out and look at it,” said Dr. Davis.
Air leaks while doing an anastomosis on the sigmoid can also lead to conversion. “If you have a Pfannenstiel incision, you can do it through the Pfannenstiel, but if you have no incision, you are probably going to want to do some kind of incision to take a peek at that,” said Dr. Davis.
In neoplasms, conversions are common to ensure negative margins, which can’t always be accomplished laparoscopically.
Severe diverticulitis is another case that can mean a conversion, but hand-assisted techniques can be employed to avoid conversion. In severe diverticulitis, ureteral catheters can be helpful. “We identified a lower incidence of ureteral injury [with the use of ureteral catheters] in diverticulitis and T4 cancers. If you have a big phlegmon or a big cancer, I would definitely consider ureteral catheters,” said Dr. Davis. He pointed out that an inability to pinpoint the ureter is daunting in these types of cases. “That’s another thing to plan on if you know you’re going into these tough cases – trying to maximize your chances of not having a conversion by giving yourself the best possible tools to and the best visualization possible,” he added.
Obesity and inflammatory bowel disease are other conversion risk factors, as is performing a left hemicolectomy versus a sigmoidectomy. “As you plan your surgery, if you know you’ve got an obese patient with bad diverticulitis, this might be someone you would schedule as a laparoscopic versus open, with minimum disposable equipment in the room, knowing that, if it’s just not going to happen, then you need to open,” said Dr. Davis.
Technical factors that can contribute to conversion include failures of staplers, clips, and energy devices. When bleeding occurs as a result of an energy device, he doesn’t repeat its use. “If the energy has failed, I go right to an endoloop,” said Dr. Davis.
Bleeding in general needs to be controlled quickly or converted to open. “If you can’t get control of bleeding, that’s when you want to make a quick decision to open. You don’t want to lose two liters of blood trying to be fancy,” said Dr. Davis.
“Cautery injuries will happen, and it doesn’t take much to cause a full-thickness injury. It’s important to address it immediately, rather than move on, since it can be difficult to find after you’ve moved on to something else. Serosal injuries should also be dealt with right away,” he said.
A staple misfire can sometimes be repaired laparoscopically, but if it can’t, the patient should be opened up. “It’s just not worth the leak to prevent an incision,” said Dr. Davis.
Finally, body mass index is a strong predictor of conversion because of the difficulties it presents. “These aren’t cases that are fun to do open, either, but it’s going to be something that we’ll have to get better and better at as we see more of these patients,” said Dr. Davis.
Global Academy for Medical Education and this news organization are owned by the same parent company.
REPORTING FROM MISS
High MIH case volume may up risk for adverse events in women with large uteri
ORLANDO – High case volume for surgeons performing minimally invasive hysterectomies in women with large uteri is associated with an increased rate of perioperative adverse events – but also with a decreased rate of conversion to laparotomy – according to a review of 763 procedures.
The minimally invasive hysterectomy (MIH) procedures in the study were performed by 66 surgeons and included 416 total laparoscopic hysterectomies, 196 robotic-assisted laparoscopic hysterectomies, 90 total vaginal hysterectomies, and 61 laparoscopic-assisted vaginal hysterectomies, Carol E. Bretschneider, MD, reported at the annual scientific meeting of the Society of Gynecologic Surgeons.
The mean monthly case volume was 16.4 and mean MIH volume was 23, said Dr. Bretschneider, a fellow at the Cleveland Clinic.
“The rate of postoperative adverse events was 17.8%, the rate of intraoperative adverse events was 4.2%, and the rate of conversion from a minimally invasive approach to a laparotomy was 5.5%,” she said, explaining that adverse events were defined as those greater than grade 2 on the Clavien-Dindo classification scale. “No differences were appreciated across routes [of MIH] in terms of perioperative adverse events or conversion to laparotomy,” she noted.
Even after investigators controlled for age, body mass index, uterine weight, history of laparotomy, and parity, as well as surgeon volume and operative time, they found that higher monthly MIH volume, estimated blood loss, and operative time remained significantly associated with both intraoperative adverse events (adjusted odds ratios, 1.9, 2.0, and 22.1, respectively) and postoperative adverse events (aOR, 1.3, 1.4, and 1.9, respectively), she said.
Higher BMI was associated with a lower incidence of intraoperative complications (aOR, 0.1).
“As for conversion to laparotomy, increasing surgeon volume was associated with a lower incidence of conversion (aOR, 0.4), but higher estimated blood loss and uterine weight were associated with a higher incidence of conversion (aOR, 2.6 and 7.1, respectively).”
Study subjects were women with a mean age of 47 years and mean BMI of 31 kg/m2 who underwent MIH during January 2014–June 2016 at a tertiary care referral center. Median uterine weight was 409 g, and indications for hysterectomy included fibroids, pelvic pain, abnormal uterine bleeding, and prolapse. Patients with malignancy were excluded.
“In the context of high-complexity cases, such as those for large uteri, many factors beyond surgical volume influence perioperative adverse events,” Dr. Bretschneider said, concluding that, to improve patient safety and outcomes, additional studies should be performed to explore the relationship between surgeon experience and patient factors on perioperative outcomes in the setting of common gynecologic procedures.
Dr. Bretschneider reported having no relevant disclosures.
SOURCE: Bretschneider C et al. SGS 2018, Oral Poster 12.
ORLANDO – High case volume for surgeons performing minimally invasive hysterectomies in women with large uteri is associated with an increased rate of perioperative adverse events – but also with a decreased rate of conversion to laparotomy – according to a review of 763 procedures.
The minimally invasive hysterectomy (MIH) procedures in the study were performed by 66 surgeons and included 416 total laparoscopic hysterectomies, 196 robotic-assisted laparoscopic hysterectomies, 90 total vaginal hysterectomies, and 61 laparoscopic-assisted vaginal hysterectomies, Carol E. Bretschneider, MD, reported at the annual scientific meeting of the Society of Gynecologic Surgeons.
The mean monthly case volume was 16.4 and mean MIH volume was 23, said Dr. Bretschneider, a fellow at the Cleveland Clinic.
“The rate of postoperative adverse events was 17.8%, the rate of intraoperative adverse events was 4.2%, and the rate of conversion from a minimally invasive approach to a laparotomy was 5.5%,” she said, explaining that adverse events were defined as those greater than grade 2 on the Clavien-Dindo classification scale. “No differences were appreciated across routes [of MIH] in terms of perioperative adverse events or conversion to laparotomy,” she noted.
Even after investigators controlled for age, body mass index, uterine weight, history of laparotomy, and parity, as well as surgeon volume and operative time, they found that higher monthly MIH volume, estimated blood loss, and operative time remained significantly associated with both intraoperative adverse events (adjusted odds ratios, 1.9, 2.0, and 22.1, respectively) and postoperative adverse events (aOR, 1.3, 1.4, and 1.9, respectively), she said.
Higher BMI was associated with a lower incidence of intraoperative complications (aOR, 0.1).
“As for conversion to laparotomy, increasing surgeon volume was associated with a lower incidence of conversion (aOR, 0.4), but higher estimated blood loss and uterine weight were associated with a higher incidence of conversion (aOR, 2.6 and 7.1, respectively).”
Study subjects were women with a mean age of 47 years and mean BMI of 31 kg/m2 who underwent MIH during January 2014–June 2016 at a tertiary care referral center. Median uterine weight was 409 g, and indications for hysterectomy included fibroids, pelvic pain, abnormal uterine bleeding, and prolapse. Patients with malignancy were excluded.
“In the context of high-complexity cases, such as those for large uteri, many factors beyond surgical volume influence perioperative adverse events,” Dr. Bretschneider said, concluding that, to improve patient safety and outcomes, additional studies should be performed to explore the relationship between surgeon experience and patient factors on perioperative outcomes in the setting of common gynecologic procedures.
Dr. Bretschneider reported having no relevant disclosures.
SOURCE: Bretschneider C et al. SGS 2018, Oral Poster 12.
ORLANDO – High case volume for surgeons performing minimally invasive hysterectomies in women with large uteri is associated with an increased rate of perioperative adverse events – but also with a decreased rate of conversion to laparotomy – according to a review of 763 procedures.
The minimally invasive hysterectomy (MIH) procedures in the study were performed by 66 surgeons and included 416 total laparoscopic hysterectomies, 196 robotic-assisted laparoscopic hysterectomies, 90 total vaginal hysterectomies, and 61 laparoscopic-assisted vaginal hysterectomies, Carol E. Bretschneider, MD, reported at the annual scientific meeting of the Society of Gynecologic Surgeons.
The mean monthly case volume was 16.4 and mean MIH volume was 23, said Dr. Bretschneider, a fellow at the Cleveland Clinic.
“The rate of postoperative adverse events was 17.8%, the rate of intraoperative adverse events was 4.2%, and the rate of conversion from a minimally invasive approach to a laparotomy was 5.5%,” she said, explaining that adverse events were defined as those greater than grade 2 on the Clavien-Dindo classification scale. “No differences were appreciated across routes [of MIH] in terms of perioperative adverse events or conversion to laparotomy,” she noted.
Even after investigators controlled for age, body mass index, uterine weight, history of laparotomy, and parity, as well as surgeon volume and operative time, they found that higher monthly MIH volume, estimated blood loss, and operative time remained significantly associated with both intraoperative adverse events (adjusted odds ratios, 1.9, 2.0, and 22.1, respectively) and postoperative adverse events (aOR, 1.3, 1.4, and 1.9, respectively), she said.
Higher BMI was associated with a lower incidence of intraoperative complications (aOR, 0.1).
“As for conversion to laparotomy, increasing surgeon volume was associated with a lower incidence of conversion (aOR, 0.4), but higher estimated blood loss and uterine weight were associated with a higher incidence of conversion (aOR, 2.6 and 7.1, respectively).”
Study subjects were women with a mean age of 47 years and mean BMI of 31 kg/m2 who underwent MIH during January 2014–June 2016 at a tertiary care referral center. Median uterine weight was 409 g, and indications for hysterectomy included fibroids, pelvic pain, abnormal uterine bleeding, and prolapse. Patients with malignancy were excluded.
“In the context of high-complexity cases, such as those for large uteri, many factors beyond surgical volume influence perioperative adverse events,” Dr. Bretschneider said, concluding that, to improve patient safety and outcomes, additional studies should be performed to explore the relationship between surgeon experience and patient factors on perioperative outcomes in the setting of common gynecologic procedures.
Dr. Bretschneider reported having no relevant disclosures.
SOURCE: Bretschneider C et al. SGS 2018, Oral Poster 12.
REPORTING FROM SGS 2018
Key clinical point: High case volume may increase risk for adverse events during minimally invasive hysterectomy with large uteri.
Major finding: MIH volume, estimated blood loss, and operative time were associated with intraoperative adverse events (odds ratios, 1.9, 2.0, and 22.1, respectively) and postoperative adverse events (ORs, 1.3, 1.4, and 1.9, respectively).
Study details: A retrospective cohort study of 763 women.
Disclosures: Dr. Bretschneider reported having no relevant disclosures.
Source: Bretschneider C et al. SGS 2018, Oral Poster 12.
A Message from the Executive Director: ACS continues to take on the issues of concern to surgeons and their patients
I am pleased to once again submit an annual report for publication in ACS Surgery News. The American College of Surgeons (ACS) had a productive year in 2017 and looks forward to seeing a range of new programs evolve in 2018.
Physician payment
A health policy issue of considerable concern to ACS Fellows is the Centers for Medicare & Medicaid Services’ efforts to implement the payment reforms in the Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act (MACRA) of 2015. Specifically, 2017 was the transition year for implementation of the Quality Payment Program’s (QPP’s) Merit-based Incentive Payment System (MIPS), and MIPS data collected in 2017 will be used to determine annual payment updates in 2019.
In 2018, the second year of MIPS, the penalty for nonparticipation has increased to 5 percent from 4 percent. Over time, the penalty for nonparticpation or poor performance will continue to rise. The College has created a variety of resources to assist Fellows in their efforts to comply with MIPS, which explain the purpose and structure of the MIPS program and help guide surgeons in choosing and achieving the goal that is right for their individual practice. These tools can be found on the ACS website at facs.org/qpp.
In addition to MIPS, the QPP calls for the establishment of Alternative Payment Models (APMs). The College has worked with thought leaders at Brandeis University, Waltham, MA, to develop the ACS-Brandeis Advanced APM. In 2017, the Secretary of the Department of Health and Human Services reviewed the proposal and made recommendations for improvement. Efforts to develop the model continue, and the ACS is working with private insurers and entities that may implement the APM model once available.
Education
The College is leading a significant effort to address the needs of surgeons who are looking to update their skills. The Steering Committee for Retraining and Retooling of Practicing Surgeons is working to define standards and establish a national infrastructure to achieve optimal outcomes. The ACS Accredited Education Institutes are at the core of this infrastructure.
At Clinical Congress 2017, we launched the ACS Academy of Master Surgeon Educators. The goals of the academy are to recognize master surgeon educators, advance the science and practice of leading-edge surgical education and training, foster innovation and collaboration, support faculty development and recognition, and underscore the importance of surgical education and training.
Also at Clinical Congress, the ACS Committee on Ethics unveiled Ethical Issues in Surgical Care, a landmark resource that defines a framework for the field of surgical ethics as it has evolved over the last decade. The book is organized into four sections that address the broad areas of general consideration, the surgeon-patient relationship, the surgeon and the surgical profession, and the surgeon and society.
Quality
The College released Optimal Resources for Surgical Quality and Safety, also known as the “red book,” in July 2017.This manual provides a guide for surgical quality leaders seeking to improve quality and safety in their institutions, departments, and practices. Efforts are under way to develop adjunctive or integrated resources/standards and to potentially establish a Surgical Quality Verification Program.
The red book was released at the 2017 ACS Quality and Safety Conference, formerly the ACS National Surgical Quality Improvement Program (ACS NSQIP®) Annual Conference, in New York, NY. The conference, which focused on a broad range of ACS Quality Programs, boasted a record-breaking attendance of more than 1,800 attendees.
The new Surgeon Specific Registry was the first ACS database to launch as part of the College’s integrated registry of the future, which ultimately will allow users to share relevant quality data across individual ACS Quality Programs, such as ACS NSQIP and the Trauma Quality Improvement Program (TQIP®).
Other new quality initiatives include the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery (ISCR), which the ACS is conducting in collaboration with Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, Baltimore, MD. This program supports hospitals in implementing perioperative evidence-based pathways to improve clinical outcomes, reduce hospital length of stay, and improve the patient experience.
The ACS also has become the new home of Strong for Surgery, originally developed by surgeons in Washington State. This program empowers hospitals and clinics to integrate checklists into the preoperative phase of care.
In addition, the ACS was awarded a three-year, multimillion dollar R01 grant from the National Institute on Minority Health and Health Disparities. ACS Past-President L.D. Britt, MD, MPH, DSc(Hon), FACS, FCCM, FRCSEng(Hon), FRCSEd(Hon), FWACS(Hon), FRCSI(Hon), FCS(SA)(Hon), FRCSGlasg(Hon), is the principal investigator on this award, which is aimed at eliminating variances in access to surgical care.
Trauma
The Committee on Trauma (COT), in collaboration with military partners and the National Highway Traffic Safety Administration (NHTSA), hosted a conference in April 2017 to advance the recommendations in the National Academies on Science, Engineering, and Medicine report, A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths after Injury. The meeting brought together approximately 170 trauma care professionals with the goal of creating the framework for a National Trauma Care System Action Plan.
In light of recent tragedies and the ongoing public debate over how to stop the continuing violence at our nation’s schools, churches, and other public places, the COT Injury Prevention and Control Committee (IPCC) is advocating for a consensus-based, public health/trauma system approach to firearm injury prevention. Furthermore, at its February 2018 meeting the ACS Board of Regents unanimously approved a plan to expand the College’s focus from the successful Stop the Bleed® program to a broader prevention initiative focused on strategies that include research, advocacy, and strategic collaborations. An action plan was in development at press time.
ACS leadership
The ACS Board of Governors (B/G) continues to implement initiatives through its Pillars and Workgroups. Specific examples from this past year include the release of a white paper on out-of-network billing; production of the biannual e-newsletter, The Cutting Edge; conduct of the 2017 Board of Governors Annual Survey, which focuses on the Stop the Bleed campaign, the opioid crisis, work-related injuries/surgical ergonomics, and advanced practice providers in surgery; and development of a standardized letter of recommendation for applicants to surgery training programs.
The ACS Board of Regents approved and updated a number of statements in the last 12 months. New statements cover several topics of concern to the Fellowship, including gender salary equity, the use of anesthetics and sedation drugs in children and pregnant women, the opioid abuse epidemic, lithium batteries, opioids and motor vehicle crash prevention, maintaining surgical access with a locum tenens surgeon, social media, the Uniform Emergency Volunteer Health Practitioners Act, credentialing and privileging, and medical students and the electronic health record.
As these few examples demonstrate, the ACS is constantly moving forward to offer surgeons and the other members of the patient care team the tools, resources, and educational opportunities they need to succeed in practice and to provide optimal patient care. As always, you are encouraged to contact the ACS leadership, and let us know how we can best serve you.
Dr. Hoyt is the Executive Director of the ACS, Chicago, IL.
I am pleased to once again submit an annual report for publication in ACS Surgery News. The American College of Surgeons (ACS) had a productive year in 2017 and looks forward to seeing a range of new programs evolve in 2018.
Physician payment
A health policy issue of considerable concern to ACS Fellows is the Centers for Medicare & Medicaid Services’ efforts to implement the payment reforms in the Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act (MACRA) of 2015. Specifically, 2017 was the transition year for implementation of the Quality Payment Program’s (QPP’s) Merit-based Incentive Payment System (MIPS), and MIPS data collected in 2017 will be used to determine annual payment updates in 2019.
In 2018, the second year of MIPS, the penalty for nonparticipation has increased to 5 percent from 4 percent. Over time, the penalty for nonparticpation or poor performance will continue to rise. The College has created a variety of resources to assist Fellows in their efforts to comply with MIPS, which explain the purpose and structure of the MIPS program and help guide surgeons in choosing and achieving the goal that is right for their individual practice. These tools can be found on the ACS website at facs.org/qpp.
In addition to MIPS, the QPP calls for the establishment of Alternative Payment Models (APMs). The College has worked with thought leaders at Brandeis University, Waltham, MA, to develop the ACS-Brandeis Advanced APM. In 2017, the Secretary of the Department of Health and Human Services reviewed the proposal and made recommendations for improvement. Efforts to develop the model continue, and the ACS is working with private insurers and entities that may implement the APM model once available.
Education
The College is leading a significant effort to address the needs of surgeons who are looking to update their skills. The Steering Committee for Retraining and Retooling of Practicing Surgeons is working to define standards and establish a national infrastructure to achieve optimal outcomes. The ACS Accredited Education Institutes are at the core of this infrastructure.
At Clinical Congress 2017, we launched the ACS Academy of Master Surgeon Educators. The goals of the academy are to recognize master surgeon educators, advance the science and practice of leading-edge surgical education and training, foster innovation and collaboration, support faculty development and recognition, and underscore the importance of surgical education and training.
Also at Clinical Congress, the ACS Committee on Ethics unveiled Ethical Issues in Surgical Care, a landmark resource that defines a framework for the field of surgical ethics as it has evolved over the last decade. The book is organized into four sections that address the broad areas of general consideration, the surgeon-patient relationship, the surgeon and the surgical profession, and the surgeon and society.
Quality
The College released Optimal Resources for Surgical Quality and Safety, also known as the “red book,” in July 2017.This manual provides a guide for surgical quality leaders seeking to improve quality and safety in their institutions, departments, and practices. Efforts are under way to develop adjunctive or integrated resources/standards and to potentially establish a Surgical Quality Verification Program.
The red book was released at the 2017 ACS Quality and Safety Conference, formerly the ACS National Surgical Quality Improvement Program (ACS NSQIP®) Annual Conference, in New York, NY. The conference, which focused on a broad range of ACS Quality Programs, boasted a record-breaking attendance of more than 1,800 attendees.
The new Surgeon Specific Registry was the first ACS database to launch as part of the College’s integrated registry of the future, which ultimately will allow users to share relevant quality data across individual ACS Quality Programs, such as ACS NSQIP and the Trauma Quality Improvement Program (TQIP®).
Other new quality initiatives include the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery (ISCR), which the ACS is conducting in collaboration with Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, Baltimore, MD. This program supports hospitals in implementing perioperative evidence-based pathways to improve clinical outcomes, reduce hospital length of stay, and improve the patient experience.
The ACS also has become the new home of Strong for Surgery, originally developed by surgeons in Washington State. This program empowers hospitals and clinics to integrate checklists into the preoperative phase of care.
In addition, the ACS was awarded a three-year, multimillion dollar R01 grant from the National Institute on Minority Health and Health Disparities. ACS Past-President L.D. Britt, MD, MPH, DSc(Hon), FACS, FCCM, FRCSEng(Hon), FRCSEd(Hon), FWACS(Hon), FRCSI(Hon), FCS(SA)(Hon), FRCSGlasg(Hon), is the principal investigator on this award, which is aimed at eliminating variances in access to surgical care.
Trauma
The Committee on Trauma (COT), in collaboration with military partners and the National Highway Traffic Safety Administration (NHTSA), hosted a conference in April 2017 to advance the recommendations in the National Academies on Science, Engineering, and Medicine report, A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths after Injury. The meeting brought together approximately 170 trauma care professionals with the goal of creating the framework for a National Trauma Care System Action Plan.
In light of recent tragedies and the ongoing public debate over how to stop the continuing violence at our nation’s schools, churches, and other public places, the COT Injury Prevention and Control Committee (IPCC) is advocating for a consensus-based, public health/trauma system approach to firearm injury prevention. Furthermore, at its February 2018 meeting the ACS Board of Regents unanimously approved a plan to expand the College’s focus from the successful Stop the Bleed® program to a broader prevention initiative focused on strategies that include research, advocacy, and strategic collaborations. An action plan was in development at press time.
ACS leadership
The ACS Board of Governors (B/G) continues to implement initiatives through its Pillars and Workgroups. Specific examples from this past year include the release of a white paper on out-of-network billing; production of the biannual e-newsletter, The Cutting Edge; conduct of the 2017 Board of Governors Annual Survey, which focuses on the Stop the Bleed campaign, the opioid crisis, work-related injuries/surgical ergonomics, and advanced practice providers in surgery; and development of a standardized letter of recommendation for applicants to surgery training programs.
The ACS Board of Regents approved and updated a number of statements in the last 12 months. New statements cover several topics of concern to the Fellowship, including gender salary equity, the use of anesthetics and sedation drugs in children and pregnant women, the opioid abuse epidemic, lithium batteries, opioids and motor vehicle crash prevention, maintaining surgical access with a locum tenens surgeon, social media, the Uniform Emergency Volunteer Health Practitioners Act, credentialing and privileging, and medical students and the electronic health record.
As these few examples demonstrate, the ACS is constantly moving forward to offer surgeons and the other members of the patient care team the tools, resources, and educational opportunities they need to succeed in practice and to provide optimal patient care. As always, you are encouraged to contact the ACS leadership, and let us know how we can best serve you.
Dr. Hoyt is the Executive Director of the ACS, Chicago, IL.
I am pleased to once again submit an annual report for publication in ACS Surgery News. The American College of Surgeons (ACS) had a productive year in 2017 and looks forward to seeing a range of new programs evolve in 2018.
Physician payment
A health policy issue of considerable concern to ACS Fellows is the Centers for Medicare & Medicaid Services’ efforts to implement the payment reforms in the Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act (MACRA) of 2015. Specifically, 2017 was the transition year for implementation of the Quality Payment Program’s (QPP’s) Merit-based Incentive Payment System (MIPS), and MIPS data collected in 2017 will be used to determine annual payment updates in 2019.
In 2018, the second year of MIPS, the penalty for nonparticipation has increased to 5 percent from 4 percent. Over time, the penalty for nonparticpation or poor performance will continue to rise. The College has created a variety of resources to assist Fellows in their efforts to comply with MIPS, which explain the purpose and structure of the MIPS program and help guide surgeons in choosing and achieving the goal that is right for their individual practice. These tools can be found on the ACS website at facs.org/qpp.
In addition to MIPS, the QPP calls for the establishment of Alternative Payment Models (APMs). The College has worked with thought leaders at Brandeis University, Waltham, MA, to develop the ACS-Brandeis Advanced APM. In 2017, the Secretary of the Department of Health and Human Services reviewed the proposal and made recommendations for improvement. Efforts to develop the model continue, and the ACS is working with private insurers and entities that may implement the APM model once available.
Education
The College is leading a significant effort to address the needs of surgeons who are looking to update their skills. The Steering Committee for Retraining and Retooling of Practicing Surgeons is working to define standards and establish a national infrastructure to achieve optimal outcomes. The ACS Accredited Education Institutes are at the core of this infrastructure.
At Clinical Congress 2017, we launched the ACS Academy of Master Surgeon Educators. The goals of the academy are to recognize master surgeon educators, advance the science and practice of leading-edge surgical education and training, foster innovation and collaboration, support faculty development and recognition, and underscore the importance of surgical education and training.
Also at Clinical Congress, the ACS Committee on Ethics unveiled Ethical Issues in Surgical Care, a landmark resource that defines a framework for the field of surgical ethics as it has evolved over the last decade. The book is organized into four sections that address the broad areas of general consideration, the surgeon-patient relationship, the surgeon and the surgical profession, and the surgeon and society.
Quality
The College released Optimal Resources for Surgical Quality and Safety, also known as the “red book,” in July 2017.This manual provides a guide for surgical quality leaders seeking to improve quality and safety in their institutions, departments, and practices. Efforts are under way to develop adjunctive or integrated resources/standards and to potentially establish a Surgical Quality Verification Program.
The red book was released at the 2017 ACS Quality and Safety Conference, formerly the ACS National Surgical Quality Improvement Program (ACS NSQIP®) Annual Conference, in New York, NY. The conference, which focused on a broad range of ACS Quality Programs, boasted a record-breaking attendance of more than 1,800 attendees.
The new Surgeon Specific Registry was the first ACS database to launch as part of the College’s integrated registry of the future, which ultimately will allow users to share relevant quality data across individual ACS Quality Programs, such as ACS NSQIP and the Trauma Quality Improvement Program (TQIP®).
Other new quality initiatives include the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery (ISCR), which the ACS is conducting in collaboration with Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, Baltimore, MD. This program supports hospitals in implementing perioperative evidence-based pathways to improve clinical outcomes, reduce hospital length of stay, and improve the patient experience.
The ACS also has become the new home of Strong for Surgery, originally developed by surgeons in Washington State. This program empowers hospitals and clinics to integrate checklists into the preoperative phase of care.
In addition, the ACS was awarded a three-year, multimillion dollar R01 grant from the National Institute on Minority Health and Health Disparities. ACS Past-President L.D. Britt, MD, MPH, DSc(Hon), FACS, FCCM, FRCSEng(Hon), FRCSEd(Hon), FWACS(Hon), FRCSI(Hon), FCS(SA)(Hon), FRCSGlasg(Hon), is the principal investigator on this award, which is aimed at eliminating variances in access to surgical care.
Trauma
The Committee on Trauma (COT), in collaboration with military partners and the National Highway Traffic Safety Administration (NHTSA), hosted a conference in April 2017 to advance the recommendations in the National Academies on Science, Engineering, and Medicine report, A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths after Injury. The meeting brought together approximately 170 trauma care professionals with the goal of creating the framework for a National Trauma Care System Action Plan.
In light of recent tragedies and the ongoing public debate over how to stop the continuing violence at our nation’s schools, churches, and other public places, the COT Injury Prevention and Control Committee (IPCC) is advocating for a consensus-based, public health/trauma system approach to firearm injury prevention. Furthermore, at its February 2018 meeting the ACS Board of Regents unanimously approved a plan to expand the College’s focus from the successful Stop the Bleed® program to a broader prevention initiative focused on strategies that include research, advocacy, and strategic collaborations. An action plan was in development at press time.
ACS leadership
The ACS Board of Governors (B/G) continues to implement initiatives through its Pillars and Workgroups. Specific examples from this past year include the release of a white paper on out-of-network billing; production of the biannual e-newsletter, The Cutting Edge; conduct of the 2017 Board of Governors Annual Survey, which focuses on the Stop the Bleed campaign, the opioid crisis, work-related injuries/surgical ergonomics, and advanced practice providers in surgery; and development of a standardized letter of recommendation for applicants to surgery training programs.
The ACS Board of Regents approved and updated a number of statements in the last 12 months. New statements cover several topics of concern to the Fellowship, including gender salary equity, the use of anesthetics and sedation drugs in children and pregnant women, the opioid abuse epidemic, lithium batteries, opioids and motor vehicle crash prevention, maintaining surgical access with a locum tenens surgeon, social media, the Uniform Emergency Volunteer Health Practitioners Act, credentialing and privileging, and medical students and the electronic health record.
As these few examples demonstrate, the ACS is constantly moving forward to offer surgeons and the other members of the patient care team the tools, resources, and educational opportunities they need to succeed in practice and to provide optimal patient care. As always, you are encouraged to contact the ACS leadership, and let us know how we can best serve you.
Dr. Hoyt is the Executive Director of the ACS, Chicago, IL.
Laparoscopic hysterectomy safest even for markedly enlarged uteri
ORLANDO – according to findings from a nationwide cohort of more than 27,000 women.
After adjusting for numerous potential confounding factors, including medical risk factors, procedure-related variables, and patient demographics, increasing uterine weight was significantly associated with increasing odds of complications – particularly after hysterectomy for uteri over 500 g, Michelle Louie, MD, reported during an oral poster session at the annual scientific meeting of the Society of Gynecologic Surgeons.
The same was true for uteri of 250-500 g (adjusted OR, 0.99, 1.73, and 1.06, respectively), she noted, adding that “abdominal hysterectomy always has the highest rate of a complication, except at above 850 g, when a vaginal hysterectomy is associated with a greater odds of complications.”
This secondary analysis was performed using prospectively collected quality improvement data abstracted from the American College of Surgeons National Surgical Quality Improvement Program database, which includes patient information and 30-day outcomes from more than 500 U.S. hospitals. Patients included in the analysis were 27,167 women who underwent a hysterectomy for benign conditions during 2014-2015 for whom uterine size was reported. Complications assessed included infection, vascular complications, reoperation, and readmission.
“Our study suggests that uterine weight is not an appropriate indication for abdominal hysterectomy – that we can, and should, offer a laparoscopic approach even for a markedly enlarged uterus,” she said. “We believe, therefore, that patients may benefit from referral to specialty surgeons who are able to offer a laparoscopic approach, even for a very large uterus.”
In response to a question from the audience about the role of physician experience in the findings, Dr. Louie said that it was not a covariate for which information was available, thus it was not included in the analysis.
“However, I think all of us realize that surgeon volume and surgeon experience is an important factor for patient safety,” she said.
Dr. Louie has received consulting fees from Teleflex.
SOURCE: Louie M et al. SGS 2018, Oral Poster 06.
ORLANDO – according to findings from a nationwide cohort of more than 27,000 women.
After adjusting for numerous potential confounding factors, including medical risk factors, procedure-related variables, and patient demographics, increasing uterine weight was significantly associated with increasing odds of complications – particularly after hysterectomy for uteri over 500 g, Michelle Louie, MD, reported during an oral poster session at the annual scientific meeting of the Society of Gynecologic Surgeons.
The same was true for uteri of 250-500 g (adjusted OR, 0.99, 1.73, and 1.06, respectively), she noted, adding that “abdominal hysterectomy always has the highest rate of a complication, except at above 850 g, when a vaginal hysterectomy is associated with a greater odds of complications.”
This secondary analysis was performed using prospectively collected quality improvement data abstracted from the American College of Surgeons National Surgical Quality Improvement Program database, which includes patient information and 30-day outcomes from more than 500 U.S. hospitals. Patients included in the analysis were 27,167 women who underwent a hysterectomy for benign conditions during 2014-2015 for whom uterine size was reported. Complications assessed included infection, vascular complications, reoperation, and readmission.
“Our study suggests that uterine weight is not an appropriate indication for abdominal hysterectomy – that we can, and should, offer a laparoscopic approach even for a markedly enlarged uterus,” she said. “We believe, therefore, that patients may benefit from referral to specialty surgeons who are able to offer a laparoscopic approach, even for a very large uterus.”
In response to a question from the audience about the role of physician experience in the findings, Dr. Louie said that it was not a covariate for which information was available, thus it was not included in the analysis.
“However, I think all of us realize that surgeon volume and surgeon experience is an important factor for patient safety,” she said.
Dr. Louie has received consulting fees from Teleflex.
SOURCE: Louie M et al. SGS 2018, Oral Poster 06.
ORLANDO – according to findings from a nationwide cohort of more than 27,000 women.
After adjusting for numerous potential confounding factors, including medical risk factors, procedure-related variables, and patient demographics, increasing uterine weight was significantly associated with increasing odds of complications – particularly after hysterectomy for uteri over 500 g, Michelle Louie, MD, reported during an oral poster session at the annual scientific meeting of the Society of Gynecologic Surgeons.
The same was true for uteri of 250-500 g (adjusted OR, 0.99, 1.73, and 1.06, respectively), she noted, adding that “abdominal hysterectomy always has the highest rate of a complication, except at above 850 g, when a vaginal hysterectomy is associated with a greater odds of complications.”
This secondary analysis was performed using prospectively collected quality improvement data abstracted from the American College of Surgeons National Surgical Quality Improvement Program database, which includes patient information and 30-day outcomes from more than 500 U.S. hospitals. Patients included in the analysis were 27,167 women who underwent a hysterectomy for benign conditions during 2014-2015 for whom uterine size was reported. Complications assessed included infection, vascular complications, reoperation, and readmission.
“Our study suggests that uterine weight is not an appropriate indication for abdominal hysterectomy – that we can, and should, offer a laparoscopic approach even for a markedly enlarged uterus,” she said. “We believe, therefore, that patients may benefit from referral to specialty surgeons who are able to offer a laparoscopic approach, even for a very large uterus.”
In response to a question from the audience about the role of physician experience in the findings, Dr. Louie said that it was not a covariate for which information was available, thus it was not included in the analysis.
“However, I think all of us realize that surgeon volume and surgeon experience is an important factor for patient safety,” she said.
Dr. Louie has received consulting fees from Teleflex.
SOURCE: Louie M et al. SGS 2018, Oral Poster 06.
REPORTING FROM SGS 2018
Key clinical point: Laparoscopic hysterectomy can and should be offered to women with uteri over 500 g.
Major finding: The odds ratios for complications after laparoscopic, abdominal, and vaginal hysterectomy for uteri over 500 g were 1.61, 2.16, and 2.57, respectively.
Study details: A secondary analysis of a nationwide cohort of 27,167 women.
Disclosures: Dr. Louie has received consulting fees from Teleflex.
Source: Louie M et al. SGS 2018, Oral Poster 06.
From the Washington Office: Gratifying success for ACS legislative advocacy efforts
On the morning of February 9, 2018, President Trump signed into law the Bipartisan Budget Act of 2018. The law included legislative priorities that were championed by the ACS and for which staff of the DC office and engaged Fellows of the College have advocated, in some cases, for a number of years.
ACS worked particularly hard in the week leading up to the passage of the Bipartisan Budget Act of 2018 with the goal of ensuring that certain items were included, and certain other items were excluded, in the Continuing Resolution (CR) under consideration by Congress to continue funding the government. The original version of the CR considered and debated by the House of Representatives early in the week included both positive and negative items. The ACS was successful in its efforts to get the Senate to consider a much-improved version of the CR – eliminating a major impediment in the House version. Ultimately, it was the Senate version that was signed into law by President Trump.
The provisions in the Bipartisan Budget Act of 2018 include:
• Flexibility for the Merit-based Incentive Payment System (MIPS) related to how much weight will be ascribed to the Cost component in an individual physician’s MIPS score as well as flexibility in setting the level at which physicians will either receive a positive or negative payment update. Without this flexibility, there was significant concern that Fellows would have significantly greater challenges in avoiding a cut under the MIPS. This language, and the effort to include it, was spearheaded and long championed by the ACS including the drafting of model legislation remedying the problem which was then provided to the leadership and staff of committees of jurisdiction.
• Easing meaningful use (MU) requirements by removing an outdated requirement directing the Secretary of Health and Human Services (HHS) to continue to make meaningful use standards increasingly stringent over time. The ACS has long advocated against increasingly stringent MU requirements that do not lead to improvements in patient care, and feels they are unnecessary and unfair to both patients and providers. Further, easing MU requirements has long been supported by ACS Fellows.
• An additional 4 years of funding for the Children’s Health Insurance Program (CHIP), bringing the reauthorization period to a total of 10 years. ACS has consistently advocated and aggressively pursued reauthorization of CHIP every time reauthorization was necessary. During the most recent negotiations, following expiration of funding in September 2017, the ACS advocated for the longest possible period of reauthorization of funds.
• Full repeal of the Independent Payment Advisory Board (IPAB), included as part of the Affordable Care Act. Though members of the board were never appointed, the ACS has fought to eliminate this advisory board of unelected bureaucrats who had the power to cut physician payment since 2010.
• Additional funding to address both the opioid epidemic and to support the work of the National Institutes of Health (NIH). The ACS has long supported funding to fight cancer and has been proactive in its response to the national crisis of opioid abuse and misuse.
• Lastly, as mentioned above, the ACS strongly opposed language in the version of the bill passed by the House that would have allowed the use of the “Misvalued Codes” as part of the “pay-for” or offset for the legislation. The ACS anticipated that this language would have unfairly resulted in significant cuts to surgeons and we were pleased that this language was not included in the version ultimately agreed to and signed into law by President Trump. We sincerely hope that this ends the use of this flawed policy.
To have this many policy priorities enacted through one legislative package is a rare occurrence for any organization and accordingly is most gratifying. The emails and phone calls delivered by Fellows during the week of February 5, in combination with the work of staff here in Washington DC, no doubt played a significant role in securing these priorities. However, the work is not done and the ACS will continue to fight for improvements to issues facing surgeons and surgical patients.
We urge all Fellows to continue participating in these efforts.
Until next month ….
On the morning of February 9, 2018, President Trump signed into law the Bipartisan Budget Act of 2018. The law included legislative priorities that were championed by the ACS and for which staff of the DC office and engaged Fellows of the College have advocated, in some cases, for a number of years.
ACS worked particularly hard in the week leading up to the passage of the Bipartisan Budget Act of 2018 with the goal of ensuring that certain items were included, and certain other items were excluded, in the Continuing Resolution (CR) under consideration by Congress to continue funding the government. The original version of the CR considered and debated by the House of Representatives early in the week included both positive and negative items. The ACS was successful in its efforts to get the Senate to consider a much-improved version of the CR – eliminating a major impediment in the House version. Ultimately, it was the Senate version that was signed into law by President Trump.
The provisions in the Bipartisan Budget Act of 2018 include:
• Flexibility for the Merit-based Incentive Payment System (MIPS) related to how much weight will be ascribed to the Cost component in an individual physician’s MIPS score as well as flexibility in setting the level at which physicians will either receive a positive or negative payment update. Without this flexibility, there was significant concern that Fellows would have significantly greater challenges in avoiding a cut under the MIPS. This language, and the effort to include it, was spearheaded and long championed by the ACS including the drafting of model legislation remedying the problem which was then provided to the leadership and staff of committees of jurisdiction.
• Easing meaningful use (MU) requirements by removing an outdated requirement directing the Secretary of Health and Human Services (HHS) to continue to make meaningful use standards increasingly stringent over time. The ACS has long advocated against increasingly stringent MU requirements that do not lead to improvements in patient care, and feels they are unnecessary and unfair to both patients and providers. Further, easing MU requirements has long been supported by ACS Fellows.
• An additional 4 years of funding for the Children’s Health Insurance Program (CHIP), bringing the reauthorization period to a total of 10 years. ACS has consistently advocated and aggressively pursued reauthorization of CHIP every time reauthorization was necessary. During the most recent negotiations, following expiration of funding in September 2017, the ACS advocated for the longest possible period of reauthorization of funds.
• Full repeal of the Independent Payment Advisory Board (IPAB), included as part of the Affordable Care Act. Though members of the board were never appointed, the ACS has fought to eliminate this advisory board of unelected bureaucrats who had the power to cut physician payment since 2010.
• Additional funding to address both the opioid epidemic and to support the work of the National Institutes of Health (NIH). The ACS has long supported funding to fight cancer and has been proactive in its response to the national crisis of opioid abuse and misuse.
• Lastly, as mentioned above, the ACS strongly opposed language in the version of the bill passed by the House that would have allowed the use of the “Misvalued Codes” as part of the “pay-for” or offset for the legislation. The ACS anticipated that this language would have unfairly resulted in significant cuts to surgeons and we were pleased that this language was not included in the version ultimately agreed to and signed into law by President Trump. We sincerely hope that this ends the use of this flawed policy.
To have this many policy priorities enacted through one legislative package is a rare occurrence for any organization and accordingly is most gratifying. The emails and phone calls delivered by Fellows during the week of February 5, in combination with the work of staff here in Washington DC, no doubt played a significant role in securing these priorities. However, the work is not done and the ACS will continue to fight for improvements to issues facing surgeons and surgical patients.
We urge all Fellows to continue participating in these efforts.
Until next month ….
On the morning of February 9, 2018, President Trump signed into law the Bipartisan Budget Act of 2018. The law included legislative priorities that were championed by the ACS and for which staff of the DC office and engaged Fellows of the College have advocated, in some cases, for a number of years.
ACS worked particularly hard in the week leading up to the passage of the Bipartisan Budget Act of 2018 with the goal of ensuring that certain items were included, and certain other items were excluded, in the Continuing Resolution (CR) under consideration by Congress to continue funding the government. The original version of the CR considered and debated by the House of Representatives early in the week included both positive and negative items. The ACS was successful in its efforts to get the Senate to consider a much-improved version of the CR – eliminating a major impediment in the House version. Ultimately, it was the Senate version that was signed into law by President Trump.
The provisions in the Bipartisan Budget Act of 2018 include:
• Flexibility for the Merit-based Incentive Payment System (MIPS) related to how much weight will be ascribed to the Cost component in an individual physician’s MIPS score as well as flexibility in setting the level at which physicians will either receive a positive or negative payment update. Without this flexibility, there was significant concern that Fellows would have significantly greater challenges in avoiding a cut under the MIPS. This language, and the effort to include it, was spearheaded and long championed by the ACS including the drafting of model legislation remedying the problem which was then provided to the leadership and staff of committees of jurisdiction.
• Easing meaningful use (MU) requirements by removing an outdated requirement directing the Secretary of Health and Human Services (HHS) to continue to make meaningful use standards increasingly stringent over time. The ACS has long advocated against increasingly stringent MU requirements that do not lead to improvements in patient care, and feels they are unnecessary and unfair to both patients and providers. Further, easing MU requirements has long been supported by ACS Fellows.
• An additional 4 years of funding for the Children’s Health Insurance Program (CHIP), bringing the reauthorization period to a total of 10 years. ACS has consistently advocated and aggressively pursued reauthorization of CHIP every time reauthorization was necessary. During the most recent negotiations, following expiration of funding in September 2017, the ACS advocated for the longest possible period of reauthorization of funds.
• Full repeal of the Independent Payment Advisory Board (IPAB), included as part of the Affordable Care Act. Though members of the board were never appointed, the ACS has fought to eliminate this advisory board of unelected bureaucrats who had the power to cut physician payment since 2010.
• Additional funding to address both the opioid epidemic and to support the work of the National Institutes of Health (NIH). The ACS has long supported funding to fight cancer and has been proactive in its response to the national crisis of opioid abuse and misuse.
• Lastly, as mentioned above, the ACS strongly opposed language in the version of the bill passed by the House that would have allowed the use of the “Misvalued Codes” as part of the “pay-for” or offset for the legislation. The ACS anticipated that this language would have unfairly resulted in significant cuts to surgeons and we were pleased that this language was not included in the version ultimately agreed to and signed into law by President Trump. We sincerely hope that this ends the use of this flawed policy.
To have this many policy priorities enacted through one legislative package is a rare occurrence for any organization and accordingly is most gratifying. The emails and phone calls delivered by Fellows during the week of February 5, in combination with the work of staff here in Washington DC, no doubt played a significant role in securing these priorities. However, the work is not done and the ACS will continue to fight for improvements to issues facing surgeons and surgical patients.
We urge all Fellows to continue participating in these efforts.
Until next month ….
From the Editors: Unexpected benefits
I am a member of several surgical societies, and more than once I’ve extolled the importance of going to meetings as part of my personal definition of a “good” surgeon.
While I mostly enjoy meetings nowadays, it hasn’t always been easy. My first experiences at surgical society meetings were painful. I was 32 years old, just out of training, and didn’t know anyone at the meetings. Receptions were the worst. My only friend sometimes was either my host or my wife. I was surrounded by these old guys, most of whom were famous.
Among the highlights of my life was being invited to join the Western Surgical Association. The year I was elected, J. David Richardson was the President. He gave such a rousing speech that at the President’s Dinner I rallied the courage to speak to the great man. When I called him “Dr. Richardson,” he waved that off and insisted I call him “Dave.” Little did I know that Dave would become one of my personal heroes and play an important part in the path that led to my being in a position to write a column such as this.
I never thought that being at a meeting might save my own life. As a devoted member of the Western Surgical Association, I breezed into Phoenix last year for the annual meeting. But I wasn’t feeling so well. Typical of a surgeon, I’d been denying that the symptoms in my abdomen and back were anything other than arthritis. Also, like most surgeons, I’d been pushing the accelerator pedal of life to the floorboard for some months. I arrived at the hotel at one in the morning with a stomach ache that clearly was becoming serious.
I lay in bed wondering what to do. Surgeons don’t get sick! Calling 911 seemed like an invitation to a 6-hour ED experience during which I would be demoted from surgeon to “the patient in Room 9” in a town where I didn’t know many people. As a surgeon, I knew that belly pain of this magnitude was not something I wanted to entrust to a nonsurgeon who was just trying to get through another long shift. This was personal.
Here’s where being a member of a surgical society became more than an academic exercise. I was in a hotel with many of the finest surgeons in the world – and I knew many of them! Among the attendees was my very good friend Margo Shoup, a first-rate cancer surgeon from Chicago. I knew she had come in that day because we were to have dinner together the next night. Rather than call her at 0300, I waited until 6. She came right over and examined me. We decided on a plan. As is always the case at a surgical meeting, one of the surgeon members is the local arrangement person. In this instance, it was none other than James Madura, MD, Chief of MIS GI surgery at Mayo Clinic, Scottsdale. We called James and when my abdomen decided to go nuclear with pain, he drove me to his hospital in his own car and got me in their ED.
The rest of the story is pretty mundane. My diagnosis turned out to be temporarily serious but benign. It was serious enough that without good people treating me, I could have done poorly. James and his fine team took superb care of me. Almost all of us go into surgery with the intent to help others. We take that extraseriously when it’s one of “us.” I can imagine the increased pressure on James when he was treating a colleague and the entire rest of the Western Surgical Association knew it. He never even broke a sweat. I am so glad he was my surgeon. His chief resident Ryan Day, MD, spent extra time with me. I saw a bunch of other residents as well. They reminded me of my fellow residents many years ago – eager, bright, and hyperdedicated. Several members of the Western came by the hospital to see me and even reviewed my images and diagnosis with me. I felt like I had a whole family of physicians who were both my friends and my support system a long way from home. I cannot thank James, Margo, and the rest enough for all they did. It’s great to feel back to normal again as well.
So, I would suggest you join and participate in the surgical societies that you think are a good fit for you. Develop those important professional relationships. Such activity will do your patients a world of good – and just might save your own life.
I am a member of several surgical societies, and more than once I’ve extolled the importance of going to meetings as part of my personal definition of a “good” surgeon.
While I mostly enjoy meetings nowadays, it hasn’t always been easy. My first experiences at surgical society meetings were painful. I was 32 years old, just out of training, and didn’t know anyone at the meetings. Receptions were the worst. My only friend sometimes was either my host or my wife. I was surrounded by these old guys, most of whom were famous.
Among the highlights of my life was being invited to join the Western Surgical Association. The year I was elected, J. David Richardson was the President. He gave such a rousing speech that at the President’s Dinner I rallied the courage to speak to the great man. When I called him “Dr. Richardson,” he waved that off and insisted I call him “Dave.” Little did I know that Dave would become one of my personal heroes and play an important part in the path that led to my being in a position to write a column such as this.
I never thought that being at a meeting might save my own life. As a devoted member of the Western Surgical Association, I breezed into Phoenix last year for the annual meeting. But I wasn’t feeling so well. Typical of a surgeon, I’d been denying that the symptoms in my abdomen and back were anything other than arthritis. Also, like most surgeons, I’d been pushing the accelerator pedal of life to the floorboard for some months. I arrived at the hotel at one in the morning with a stomach ache that clearly was becoming serious.
I lay in bed wondering what to do. Surgeons don’t get sick! Calling 911 seemed like an invitation to a 6-hour ED experience during which I would be demoted from surgeon to “the patient in Room 9” in a town where I didn’t know many people. As a surgeon, I knew that belly pain of this magnitude was not something I wanted to entrust to a nonsurgeon who was just trying to get through another long shift. This was personal.
Here’s where being a member of a surgical society became more than an academic exercise. I was in a hotel with many of the finest surgeons in the world – and I knew many of them! Among the attendees was my very good friend Margo Shoup, a first-rate cancer surgeon from Chicago. I knew she had come in that day because we were to have dinner together the next night. Rather than call her at 0300, I waited until 6. She came right over and examined me. We decided on a plan. As is always the case at a surgical meeting, one of the surgeon members is the local arrangement person. In this instance, it was none other than James Madura, MD, Chief of MIS GI surgery at Mayo Clinic, Scottsdale. We called James and when my abdomen decided to go nuclear with pain, he drove me to his hospital in his own car and got me in their ED.
The rest of the story is pretty mundane. My diagnosis turned out to be temporarily serious but benign. It was serious enough that without good people treating me, I could have done poorly. James and his fine team took superb care of me. Almost all of us go into surgery with the intent to help others. We take that extraseriously when it’s one of “us.” I can imagine the increased pressure on James when he was treating a colleague and the entire rest of the Western Surgical Association knew it. He never even broke a sweat. I am so glad he was my surgeon. His chief resident Ryan Day, MD, spent extra time with me. I saw a bunch of other residents as well. They reminded me of my fellow residents many years ago – eager, bright, and hyperdedicated. Several members of the Western came by the hospital to see me and even reviewed my images and diagnosis with me. I felt like I had a whole family of physicians who were both my friends and my support system a long way from home. I cannot thank James, Margo, and the rest enough for all they did. It’s great to feel back to normal again as well.
So, I would suggest you join and participate in the surgical societies that you think are a good fit for you. Develop those important professional relationships. Such activity will do your patients a world of good – and just might save your own life.
I am a member of several surgical societies, and more than once I’ve extolled the importance of going to meetings as part of my personal definition of a “good” surgeon.
While I mostly enjoy meetings nowadays, it hasn’t always been easy. My first experiences at surgical society meetings were painful. I was 32 years old, just out of training, and didn’t know anyone at the meetings. Receptions were the worst. My only friend sometimes was either my host or my wife. I was surrounded by these old guys, most of whom were famous.
Among the highlights of my life was being invited to join the Western Surgical Association. The year I was elected, J. David Richardson was the President. He gave such a rousing speech that at the President’s Dinner I rallied the courage to speak to the great man. When I called him “Dr. Richardson,” he waved that off and insisted I call him “Dave.” Little did I know that Dave would become one of my personal heroes and play an important part in the path that led to my being in a position to write a column such as this.
I never thought that being at a meeting might save my own life. As a devoted member of the Western Surgical Association, I breezed into Phoenix last year for the annual meeting. But I wasn’t feeling so well. Typical of a surgeon, I’d been denying that the symptoms in my abdomen and back were anything other than arthritis. Also, like most surgeons, I’d been pushing the accelerator pedal of life to the floorboard for some months. I arrived at the hotel at one in the morning with a stomach ache that clearly was becoming serious.
I lay in bed wondering what to do. Surgeons don’t get sick! Calling 911 seemed like an invitation to a 6-hour ED experience during which I would be demoted from surgeon to “the patient in Room 9” in a town where I didn’t know many people. As a surgeon, I knew that belly pain of this magnitude was not something I wanted to entrust to a nonsurgeon who was just trying to get through another long shift. This was personal.
Here’s where being a member of a surgical society became more than an academic exercise. I was in a hotel with many of the finest surgeons in the world – and I knew many of them! Among the attendees was my very good friend Margo Shoup, a first-rate cancer surgeon from Chicago. I knew she had come in that day because we were to have dinner together the next night. Rather than call her at 0300, I waited until 6. She came right over and examined me. We decided on a plan. As is always the case at a surgical meeting, one of the surgeon members is the local arrangement person. In this instance, it was none other than James Madura, MD, Chief of MIS GI surgery at Mayo Clinic, Scottsdale. We called James and when my abdomen decided to go nuclear with pain, he drove me to his hospital in his own car and got me in their ED.
The rest of the story is pretty mundane. My diagnosis turned out to be temporarily serious but benign. It was serious enough that without good people treating me, I could have done poorly. James and his fine team took superb care of me. Almost all of us go into surgery with the intent to help others. We take that extraseriously when it’s one of “us.” I can imagine the increased pressure on James when he was treating a colleague and the entire rest of the Western Surgical Association knew it. He never even broke a sweat. I am so glad he was my surgeon. His chief resident Ryan Day, MD, spent extra time with me. I saw a bunch of other residents as well. They reminded me of my fellow residents many years ago – eager, bright, and hyperdedicated. Several members of the Western came by the hospital to see me and even reviewed my images and diagnosis with me. I felt like I had a whole family of physicians who were both my friends and my support system a long way from home. I cannot thank James, Margo, and the rest enough for all they did. It’s great to feel back to normal again as well.
So, I would suggest you join and participate in the surgical societies that you think are a good fit for you. Develop those important professional relationships. Such activity will do your patients a world of good – and just might save your own life.
Eileen Metzger Bulger, MD, FACS, is new Chair of the ACS Committee on Trauma
Eileen Metzger Bulger, MD, FACS, chief of trauma and trauma medical director for adults and pediatrics, Harborview Medical Center, Seattle, WA, begins serving as the new Chair of the American College of Surgeons (ACS) Committee on Trauma (COT) this month. Dr. Bulger was appointed as the next COT Chair in October 2017 by the ACS Board of Regents. She is the 20th Chair of the COT, succeeding Ronald M. Stewart, MD, FACS, of San Antonio, TX.
“We look forward to Dr. Bulger’s exceptional vision and leadership as she directs the COT into its 96th year of working to improve the care of the injured patient. She is the perfect person to lead the COT into its next century of transforming care and reducing injuries across the globe,” Dr. Stewart said.
A diplomate of the American Board of Surgery, Dr. Bulger also is board certified in surgical critical care. She earned a medical doctorate at Cornell University Medical College, New York, NY (1992). She completed a residency in general surgery at the University of Washington (UW), Seattle (1992–1999), where she concurrently completed a two-year National Institutes of Health Trauma Research Fellowship during her years of residency training (1995–1997), and then went on to complete a surgical critical care fellowship at UW in 2000.
Recognized leadership
Throughout her career, Dr. Bulger has mentored many surgical residents in paper and scholarship competitions. For nearly two decades, she has served as the co-principal or principal investigator of a variety of innovative, grant-funded research projects related to trauma care, some of which focus on improving outcomes for crash injury victims, pediatric patients, and older adults.
Since her initial involvement with the COT in 2002, Dr. Bulger has contributed to many COT activities, often serving in a leadership role. She is a Course Instructor for the internationally recognized Advanced Traum
The COT is dedicated to all phases of injury care, from prevention to rehabilitation. The committee is supported by a network of 65 state and provincial committees, 11 international committees, and five military committees, and the majority of members are ACS Fellows.
Eileen Metzger Bulger, MD, FACS, chief of trauma and trauma medical director for adults and pediatrics, Harborview Medical Center, Seattle, WA, begins serving as the new Chair of the American College of Surgeons (ACS) Committee on Trauma (COT) this month. Dr. Bulger was appointed as the next COT Chair in October 2017 by the ACS Board of Regents. She is the 20th Chair of the COT, succeeding Ronald M. Stewart, MD, FACS, of San Antonio, TX.
“We look forward to Dr. Bulger’s exceptional vision and leadership as she directs the COT into its 96th year of working to improve the care of the injured patient. She is the perfect person to lead the COT into its next century of transforming care and reducing injuries across the globe,” Dr. Stewart said.
A diplomate of the American Board of Surgery, Dr. Bulger also is board certified in surgical critical care. She earned a medical doctorate at Cornell University Medical College, New York, NY (1992). She completed a residency in general surgery at the University of Washington (UW), Seattle (1992–1999), where she concurrently completed a two-year National Institutes of Health Trauma Research Fellowship during her years of residency training (1995–1997), and then went on to complete a surgical critical care fellowship at UW in 2000.
Recognized leadership
Throughout her career, Dr. Bulger has mentored many surgical residents in paper and scholarship competitions. For nearly two decades, she has served as the co-principal or principal investigator of a variety of innovative, grant-funded research projects related to trauma care, some of which focus on improving outcomes for crash injury victims, pediatric patients, and older adults.
Since her initial involvement with the COT in 2002, Dr. Bulger has contributed to many COT activities, often serving in a leadership role. She is a Course Instructor for the internationally recognized Advanced Traum
The COT is dedicated to all phases of injury care, from prevention to rehabilitation. The committee is supported by a network of 65 state and provincial committees, 11 international committees, and five military committees, and the majority of members are ACS Fellows.
Eileen Metzger Bulger, MD, FACS, chief of trauma and trauma medical director for adults and pediatrics, Harborview Medical Center, Seattle, WA, begins serving as the new Chair of the American College of Surgeons (ACS) Committee on Trauma (COT) this month. Dr. Bulger was appointed as the next COT Chair in October 2017 by the ACS Board of Regents. She is the 20th Chair of the COT, succeeding Ronald M. Stewart, MD, FACS, of San Antonio, TX.
“We look forward to Dr. Bulger’s exceptional vision and leadership as she directs the COT into its 96th year of working to improve the care of the injured patient. She is the perfect person to lead the COT into its next century of transforming care and reducing injuries across the globe,” Dr. Stewart said.
A diplomate of the American Board of Surgery, Dr. Bulger also is board certified in surgical critical care. She earned a medical doctorate at Cornell University Medical College, New York, NY (1992). She completed a residency in general surgery at the University of Washington (UW), Seattle (1992–1999), where she concurrently completed a two-year National Institutes of Health Trauma Research Fellowship during her years of residency training (1995–1997), and then went on to complete a surgical critical care fellowship at UW in 2000.
Recognized leadership
Throughout her career, Dr. Bulger has mentored many surgical residents in paper and scholarship competitions. For nearly two decades, she has served as the co-principal or principal investigator of a variety of innovative, grant-funded research projects related to trauma care, some of which focus on improving outcomes for crash injury victims, pediatric patients, and older adults.
Since her initial involvement with the COT in 2002, Dr. Bulger has contributed to many COT activities, often serving in a leadership role. She is a Course Instructor for the internationally recognized Advanced Traum
The COT is dedicated to all phases of injury care, from prevention to rehabilitation. The committee is supported by a network of 65 state and provincial committees, 11 international committees, and five military committees, and the majority of members are ACS Fellows.
Bipartisan Budget Act of 2018 addresses ACS priorities
On February 9, Congress passed and President Trump signed into law the Bipartisan Budget Act of 2018. The law addresses many key physician and patient issues, including important technical corrections to the Merit-based Incentive Payment System (MIPS) that the American College of Surgeons (ACS) strongly favors.
The law addresses several other ACS priorities, including:
The addition of a long-term funding extension (10 years) for the Children’s Health Insurance Program (CHIP), ensuring that children continue to have access to surgical care
The inclusion of language that eases electronic health record system meaningful use requirements, alleviating some of the burdens imposed on physicians and their practices
Additional funding to address the opioid epidemic and to support the work of the National Institutes of Health Repeal of the Independent Payment Advisory Board
For more information, contact Mark Lukaszewski, ACS Congressional Lobbyist, at [email protected].
On February 9, Congress passed and President Trump signed into law the Bipartisan Budget Act of 2018. The law addresses many key physician and patient issues, including important technical corrections to the Merit-based Incentive Payment System (MIPS) that the American College of Surgeons (ACS) strongly favors.
The law addresses several other ACS priorities, including:
The addition of a long-term funding extension (10 years) for the Children’s Health Insurance Program (CHIP), ensuring that children continue to have access to surgical care
The inclusion of language that eases electronic health record system meaningful use requirements, alleviating some of the burdens imposed on physicians and their practices
Additional funding to address the opioid epidemic and to support the work of the National Institutes of Health Repeal of the Independent Payment Advisory Board
For more information, contact Mark Lukaszewski, ACS Congressional Lobbyist, at [email protected].
On February 9, Congress passed and President Trump signed into law the Bipartisan Budget Act of 2018. The law addresses many key physician and patient issues, including important technical corrections to the Merit-based Incentive Payment System (MIPS) that the American College of Surgeons (ACS) strongly favors.
The law addresses several other ACS priorities, including:
The addition of a long-term funding extension (10 years) for the Children’s Health Insurance Program (CHIP), ensuring that children continue to have access to surgical care
The inclusion of language that eases electronic health record system meaningful use requirements, alleviating some of the burdens imposed on physicians and their practices
Additional funding to address the opioid epidemic and to support the work of the National Institutes of Health Repeal of the Independent Payment Advisory Board
For more information, contact Mark Lukaszewski, ACS Congressional Lobbyist, at [email protected].
ACS delegation shapes policy at AMA HOD meeting
The American Medical Association (AMA) Interim Meeting of the House of Delegates (HOD) took place November 11–14, 2017, in Honolulu, HI. A total of 532 delegates were in attendance to debate the policy implications of 36 reports and 99 resolutions.
The American College of Surgeons (ACS) sent a six-member delegation to the meeting. The ACS also participates in AMA activities in other capacities, including in the AMA Young Physician Section Assembly, the AMA Resident and Fellow Section Assembly, and the AMA Council on Medical Education. These three groups met in conjunction with the HOD meeting. See the sidebar on page 74 for the list of ACS delegates and their other AMA roles.
ACS cosponsored issues
The AMA HOD brings together a variety of perspectives in medicine, and the job of the ACS delegation is to shape AMA policy consistent with College priorities. One way the ACS achieves this objective is by cosponsoring resolutions that have been submitted by other delegations and that are relevant to the College Fellowship. The ACS delegation cosponsored the following three resolutions at the November meeting—two on scope-of-practice issues and one on physician payment—all of which were adopted.
Resolution 214, Advanced Practice Registered Nurse (APRN) Compact, was initiated by the American Society of Anesthesiologists and strengthened with amendments. AMA policy opposes enactment of the Advanced APRN Multistate Compact because of its potential to supersede state laws that require APRNs to practice under physician supervision, as well as legislation that authorizes the independent practice of medicine by any individual who has not completed the state’s requirement for licensure to practice medicine. The AMA will convene an in-person meeting of relevant physician stakeholders to create a consistent national strategy to prevent fulfillment of the APRN Compact.
Resolution 230, Oppose Physician Assistant Independent Practice, with support from a spectrum of state medical and national specialty societies, continued the theme of opposition to legislation or regulation that allows physician extenders—in this case physician assistants—to practice independently. Another resolution addressed the emerging advanced physician assistant degree known as doctor of medical science. The AMA opposes holders of this degree from being recognized as a new category of health care practitioners licensed for the independent practice of medicine.
Resolution 808, Opposition to Reduced Payment for the 25-Modifier, was offered by the American Academy of Dermatology. The resolution was a response to private insurers discounting evaluation and management (E/M) codes by 50 percent when linked through the 25-modifier to a procedure on the same day. This resolution passed as simplified by amendment to have AMA aggressively and immediately advocate, through any legal means possible (such as direct payor negotiations, regulations, legislation, or litigation), for non-reduced allowable payment of appropriately reported 25-modifier E/M codes when linked with procedures.
Other HOD-adopted resolutions of interest
BOT (Board of Trustees) Report 5, Effective Peer Review, amended the AMA Physician and Medical Staff Member Bill of Rights to add “protection from any retaliatory actions” to the list of immunity rights when physicians participate in good faith peer-review activities. In testimony at the reference committee, the delegation highlighted the value of the new ACS “red book,” Optimal Resources for Surgical Quality and Safety, for establishing peer-review standards in surgical care.
Council on Science and Public Health Report 2, Targeted Education to Increase Organ Donation, amended the AMA policy, Methods to Increase the U.S. Organ Donor Pool. As a result, the AMA supports studies that evaluate the effectiveness of mandated choice and presumed consent models for increasing organ donation and urges development of effective methods to inform populations with historically low participation rates about donating.
Resolution 953, Fees for Taking Maintenance of Certification (MOC) Examination, amended AMA MOC policy to assert that the MOC process should reflect the cost of development and administration of the MOC components, ensure a fair fee structure, and not hinder patient care. The AMA will advocate that value in MOC includes cost-effectiveness with full financial transparency, respect for physicians’ time and patient care commitments, alignment of MOC requirements with other regulator and payor requirements, and adherence to an evidence basis for both MOC content and processes.
Not every item was viewed favorably at the AMA meeting. Council on Ethical and Judicial Affairs (CEJA) Report 1, Competence, Self-Assessment and Self-Awareness, sought to provide guidance for physicians in determining their own competence when practicing medicine. The council observed, “As an ethical responsibility, competence encompasses more than medical knowledge and skill. It requires physicians to understand that as a practical matter in the care of actual patients, competence is fluid and dependent on context.” Considerable testimony emphasized a lack of reliable tools and available resources to assist physicians in self-assessment. Thus, the report was referred back to CEJA for more work.
Surgical caucus
In addition to facilitating an agenda review and business meeting for surgeons, anesthesiologists, and emergency physicians, the caucus sponsored a popular education session, Hazards of the Deep: Trauma in Paradise. Michael Hayashi, MD, FACS, Chair of the Hawaii Committee on Trauma, discussed system challenges in caring for injured patients from geographically remote and less populated areas. Lieutenant Matthew Brown, MC, USN, an undersea/diving medical officer stationed at Pearl Harbor, HI, shared insights about injuries and medical conditions experienced by scuba divers, swimmers, surfers, and other beach enthusiasts.
Leadership transition
After extended service on the delegation, including eight years as Chair, Dr. Armstrong bid “aloha” to the HOD as a retiring delegate. Dr. Turner has accepted the role as Chair, maintaining continued College leadership in the HOD.
Next meeting
The next meeting of the AMA HOD is scheduled for June 9–13 in Chicago, IL. In addition to debate on numerous issues, elections for AMA officers, trustees, and councils will be held at the meeting. Surgeons with suggestions for potential resolutions or questions about ACS activities at the AMA HOD should e-mail [email protected]
ACS Delegation at the AMA HOD
John H. Armstrong, MD, FACS (Delegation Chair), acute care surgery, Tampa, FL
Brian J. Gavitt, MD, MPH (also Young Physicians Section delegate), general surgery, Cincinnati, OH
Jacob Moalem, MD, FACS, general surgery, Rochester, NY
Leigh A. Neumayer, MD, FACS, general surgery, Tucson, AZ; Chair, ACS Board of Regents
Naveen F. Sangji, MD (also Resident and Fellow Section delegate), general surgery resident, Boston, MA
Patricia L. Turner, MD, FACS, general surgery, Chicago, IL; Director, ACS Division of Member Services; member and immediate past-chair, AMA Council on Medical EducationDr. Armstrong is affiliate associate professor of surgery, University of South Florida Morsani College of Medicine, Tampa, and former Florida Surgeon General and Secretary of Health (2012–2016). He is a member, ACS Health Policy and Advocacy Group, and Past-Chair, ACS Professional Association political action committee (ACSPA-SurgeonsPAC).
Mr. Sutton is Manager, State Affairs, ACS Division of Advocacy and Health Policy.
The American Medical Association (AMA) Interim Meeting of the House of Delegates (HOD) took place November 11–14, 2017, in Honolulu, HI. A total of 532 delegates were in attendance to debate the policy implications of 36 reports and 99 resolutions.
The American College of Surgeons (ACS) sent a six-member delegation to the meeting. The ACS also participates in AMA activities in other capacities, including in the AMA Young Physician Section Assembly, the AMA Resident and Fellow Section Assembly, and the AMA Council on Medical Education. These three groups met in conjunction with the HOD meeting. See the sidebar on page 74 for the list of ACS delegates and their other AMA roles.
ACS cosponsored issues
The AMA HOD brings together a variety of perspectives in medicine, and the job of the ACS delegation is to shape AMA policy consistent with College priorities. One way the ACS achieves this objective is by cosponsoring resolutions that have been submitted by other delegations and that are relevant to the College Fellowship. The ACS delegation cosponsored the following three resolutions at the November meeting—two on scope-of-practice issues and one on physician payment—all of which were adopted.
Resolution 214, Advanced Practice Registered Nurse (APRN) Compact, was initiated by the American Society of Anesthesiologists and strengthened with amendments. AMA policy opposes enactment of the Advanced APRN Multistate Compact because of its potential to supersede state laws that require APRNs to practice under physician supervision, as well as legislation that authorizes the independent practice of medicine by any individual who has not completed the state’s requirement for licensure to practice medicine. The AMA will convene an in-person meeting of relevant physician stakeholders to create a consistent national strategy to prevent fulfillment of the APRN Compact.
Resolution 230, Oppose Physician Assistant Independent Practice, with support from a spectrum of state medical and national specialty societies, continued the theme of opposition to legislation or regulation that allows physician extenders—in this case physician assistants—to practice independently. Another resolution addressed the emerging advanced physician assistant degree known as doctor of medical science. The AMA opposes holders of this degree from being recognized as a new category of health care practitioners licensed for the independent practice of medicine.
Resolution 808, Opposition to Reduced Payment for the 25-Modifier, was offered by the American Academy of Dermatology. The resolution was a response to private insurers discounting evaluation and management (E/M) codes by 50 percent when linked through the 25-modifier to a procedure on the same day. This resolution passed as simplified by amendment to have AMA aggressively and immediately advocate, through any legal means possible (such as direct payor negotiations, regulations, legislation, or litigation), for non-reduced allowable payment of appropriately reported 25-modifier E/M codes when linked with procedures.
Other HOD-adopted resolutions of interest
BOT (Board of Trustees) Report 5, Effective Peer Review, amended the AMA Physician and Medical Staff Member Bill of Rights to add “protection from any retaliatory actions” to the list of immunity rights when physicians participate in good faith peer-review activities. In testimony at the reference committee, the delegation highlighted the value of the new ACS “red book,” Optimal Resources for Surgical Quality and Safety, for establishing peer-review standards in surgical care.
Council on Science and Public Health Report 2, Targeted Education to Increase Organ Donation, amended the AMA policy, Methods to Increase the U.S. Organ Donor Pool. As a result, the AMA supports studies that evaluate the effectiveness of mandated choice and presumed consent models for increasing organ donation and urges development of effective methods to inform populations with historically low participation rates about donating.
Resolution 953, Fees for Taking Maintenance of Certification (MOC) Examination, amended AMA MOC policy to assert that the MOC process should reflect the cost of development and administration of the MOC components, ensure a fair fee structure, and not hinder patient care. The AMA will advocate that value in MOC includes cost-effectiveness with full financial transparency, respect for physicians’ time and patient care commitments, alignment of MOC requirements with other regulator and payor requirements, and adherence to an evidence basis for both MOC content and processes.
Not every item was viewed favorably at the AMA meeting. Council on Ethical and Judicial Affairs (CEJA) Report 1, Competence, Self-Assessment and Self-Awareness, sought to provide guidance for physicians in determining their own competence when practicing medicine. The council observed, “As an ethical responsibility, competence encompasses more than medical knowledge and skill. It requires physicians to understand that as a practical matter in the care of actual patients, competence is fluid and dependent on context.” Considerable testimony emphasized a lack of reliable tools and available resources to assist physicians in self-assessment. Thus, the report was referred back to CEJA for more work.
Surgical caucus
In addition to facilitating an agenda review and business meeting for surgeons, anesthesiologists, and emergency physicians, the caucus sponsored a popular education session, Hazards of the Deep: Trauma in Paradise. Michael Hayashi, MD, FACS, Chair of the Hawaii Committee on Trauma, discussed system challenges in caring for injured patients from geographically remote and less populated areas. Lieutenant Matthew Brown, MC, USN, an undersea/diving medical officer stationed at Pearl Harbor, HI, shared insights about injuries and medical conditions experienced by scuba divers, swimmers, surfers, and other beach enthusiasts.
Leadership transition
After extended service on the delegation, including eight years as Chair, Dr. Armstrong bid “aloha” to the HOD as a retiring delegate. Dr. Turner has accepted the role as Chair, maintaining continued College leadership in the HOD.
Next meeting
The next meeting of the AMA HOD is scheduled for June 9–13 in Chicago, IL. In addition to debate on numerous issues, elections for AMA officers, trustees, and councils will be held at the meeting. Surgeons with suggestions for potential resolutions or questions about ACS activities at the AMA HOD should e-mail [email protected]
ACS Delegation at the AMA HOD
John H. Armstrong, MD, FACS (Delegation Chair), acute care surgery, Tampa, FL
Brian J. Gavitt, MD, MPH (also Young Physicians Section delegate), general surgery, Cincinnati, OH
Jacob Moalem, MD, FACS, general surgery, Rochester, NY
Leigh A. Neumayer, MD, FACS, general surgery, Tucson, AZ; Chair, ACS Board of Regents
Naveen F. Sangji, MD (also Resident and Fellow Section delegate), general surgery resident, Boston, MA
Patricia L. Turner, MD, FACS, general surgery, Chicago, IL; Director, ACS Division of Member Services; member and immediate past-chair, AMA Council on Medical EducationDr. Armstrong is affiliate associate professor of surgery, University of South Florida Morsani College of Medicine, Tampa, and former Florida Surgeon General and Secretary of Health (2012–2016). He is a member, ACS Health Policy and Advocacy Group, and Past-Chair, ACS Professional Association political action committee (ACSPA-SurgeonsPAC).
Mr. Sutton is Manager, State Affairs, ACS Division of Advocacy and Health Policy.
The American Medical Association (AMA) Interim Meeting of the House of Delegates (HOD) took place November 11–14, 2017, in Honolulu, HI. A total of 532 delegates were in attendance to debate the policy implications of 36 reports and 99 resolutions.
The American College of Surgeons (ACS) sent a six-member delegation to the meeting. The ACS also participates in AMA activities in other capacities, including in the AMA Young Physician Section Assembly, the AMA Resident and Fellow Section Assembly, and the AMA Council on Medical Education. These three groups met in conjunction with the HOD meeting. See the sidebar on page 74 for the list of ACS delegates and their other AMA roles.
ACS cosponsored issues
The AMA HOD brings together a variety of perspectives in medicine, and the job of the ACS delegation is to shape AMA policy consistent with College priorities. One way the ACS achieves this objective is by cosponsoring resolutions that have been submitted by other delegations and that are relevant to the College Fellowship. The ACS delegation cosponsored the following three resolutions at the November meeting—two on scope-of-practice issues and one on physician payment—all of which were adopted.
Resolution 214, Advanced Practice Registered Nurse (APRN) Compact, was initiated by the American Society of Anesthesiologists and strengthened with amendments. AMA policy opposes enactment of the Advanced APRN Multistate Compact because of its potential to supersede state laws that require APRNs to practice under physician supervision, as well as legislation that authorizes the independent practice of medicine by any individual who has not completed the state’s requirement for licensure to practice medicine. The AMA will convene an in-person meeting of relevant physician stakeholders to create a consistent national strategy to prevent fulfillment of the APRN Compact.
Resolution 230, Oppose Physician Assistant Independent Practice, with support from a spectrum of state medical and national specialty societies, continued the theme of opposition to legislation or regulation that allows physician extenders—in this case physician assistants—to practice independently. Another resolution addressed the emerging advanced physician assistant degree known as doctor of medical science. The AMA opposes holders of this degree from being recognized as a new category of health care practitioners licensed for the independent practice of medicine.
Resolution 808, Opposition to Reduced Payment for the 25-Modifier, was offered by the American Academy of Dermatology. The resolution was a response to private insurers discounting evaluation and management (E/M) codes by 50 percent when linked through the 25-modifier to a procedure on the same day. This resolution passed as simplified by amendment to have AMA aggressively and immediately advocate, through any legal means possible (such as direct payor negotiations, regulations, legislation, or litigation), for non-reduced allowable payment of appropriately reported 25-modifier E/M codes when linked with procedures.
Other HOD-adopted resolutions of interest
BOT (Board of Trustees) Report 5, Effective Peer Review, amended the AMA Physician and Medical Staff Member Bill of Rights to add “protection from any retaliatory actions” to the list of immunity rights when physicians participate in good faith peer-review activities. In testimony at the reference committee, the delegation highlighted the value of the new ACS “red book,” Optimal Resources for Surgical Quality and Safety, for establishing peer-review standards in surgical care.
Council on Science and Public Health Report 2, Targeted Education to Increase Organ Donation, amended the AMA policy, Methods to Increase the U.S. Organ Donor Pool. As a result, the AMA supports studies that evaluate the effectiveness of mandated choice and presumed consent models for increasing organ donation and urges development of effective methods to inform populations with historically low participation rates about donating.
Resolution 953, Fees for Taking Maintenance of Certification (MOC) Examination, amended AMA MOC policy to assert that the MOC process should reflect the cost of development and administration of the MOC components, ensure a fair fee structure, and not hinder patient care. The AMA will advocate that value in MOC includes cost-effectiveness with full financial transparency, respect for physicians’ time and patient care commitments, alignment of MOC requirements with other regulator and payor requirements, and adherence to an evidence basis for both MOC content and processes.
Not every item was viewed favorably at the AMA meeting. Council on Ethical and Judicial Affairs (CEJA) Report 1, Competence, Self-Assessment and Self-Awareness, sought to provide guidance for physicians in determining their own competence when practicing medicine. The council observed, “As an ethical responsibility, competence encompasses more than medical knowledge and skill. It requires physicians to understand that as a practical matter in the care of actual patients, competence is fluid and dependent on context.” Considerable testimony emphasized a lack of reliable tools and available resources to assist physicians in self-assessment. Thus, the report was referred back to CEJA for more work.
Surgical caucus
In addition to facilitating an agenda review and business meeting for surgeons, anesthesiologists, and emergency physicians, the caucus sponsored a popular education session, Hazards of the Deep: Trauma in Paradise. Michael Hayashi, MD, FACS, Chair of the Hawaii Committee on Trauma, discussed system challenges in caring for injured patients from geographically remote and less populated areas. Lieutenant Matthew Brown, MC, USN, an undersea/diving medical officer stationed at Pearl Harbor, HI, shared insights about injuries and medical conditions experienced by scuba divers, swimmers, surfers, and other beach enthusiasts.
Leadership transition
After extended service on the delegation, including eight years as Chair, Dr. Armstrong bid “aloha” to the HOD as a retiring delegate. Dr. Turner has accepted the role as Chair, maintaining continued College leadership in the HOD.
Next meeting
The next meeting of the AMA HOD is scheduled for June 9–13 in Chicago, IL. In addition to debate on numerous issues, elections for AMA officers, trustees, and councils will be held at the meeting. Surgeons with suggestions for potential resolutions or questions about ACS activities at the AMA HOD should e-mail [email protected]
ACS Delegation at the AMA HOD
John H. Armstrong, MD, FACS (Delegation Chair), acute care surgery, Tampa, FL
Brian J. Gavitt, MD, MPH (also Young Physicians Section delegate), general surgery, Cincinnati, OH
Jacob Moalem, MD, FACS, general surgery, Rochester, NY
Leigh A. Neumayer, MD, FACS, general surgery, Tucson, AZ; Chair, ACS Board of Regents
Naveen F. Sangji, MD (also Resident and Fellow Section delegate), general surgery resident, Boston, MA
Patricia L. Turner, MD, FACS, general surgery, Chicago, IL; Director, ACS Division of Member Services; member and immediate past-chair, AMA Council on Medical EducationDr. Armstrong is affiliate associate professor of surgery, University of South Florida Morsani College of Medicine, Tampa, and former Florida Surgeon General and Secretary of Health (2012–2016). He is a member, ACS Health Policy and Advocacy Group, and Past-Chair, ACS Professional Association political action committee (ACSPA-SurgeonsPAC).
Mr. Sutton is Manager, State Affairs, ACS Division of Advocacy and Health Policy.
Register for an upcoming 2018 ACS General Surgery Coding Workshop
Registration is open to attend an American College of Surgeons (ACS) 2018 General Surgery Coding Workshop. With Medicare and third-party payor policy and coding changes taking effect this year, it is imperative that surgeons have accurate and up-to-date information to protect their reimbursements and optimize efficiency.
During the coding workshop, you will learn how to report surgical procedures and medical services and will have access to the tools necessary to succeed, including a coding workbook to keep for future reference with checklists, resource guides, templates, and examples. Physicians receive up to 6.5 AMA PRA Category 1 Credits™ for each day of participation. In addition, each day of the workshop meets AAPC guidelines for 6.5 continuing education units.
The ACS will offer the following five remaining coding workshops in 2018:
Chicago, IL, April 12–13
New York, NY, May 17–19
Nashville, TN, August 9–10
Chicago, IL, November 1–3
The ACS also will offer a three-day course, including a day devoted to trauma and critical care coding at the New York City and (November) Chicago workshops.
Register for a course at www.karenzupko.com/workshops2/gensurg-workshops/. For more information about the 2018 ACS coding workshops, visit the ACS website www.facs.org/advocacy/practmanagement/workshops or e-mail
Registration is open to attend an American College of Surgeons (ACS) 2018 General Surgery Coding Workshop. With Medicare and third-party payor policy and coding changes taking effect this year, it is imperative that surgeons have accurate and up-to-date information to protect their reimbursements and optimize efficiency.
During the coding workshop, you will learn how to report surgical procedures and medical services and will have access to the tools necessary to succeed, including a coding workbook to keep for future reference with checklists, resource guides, templates, and examples. Physicians receive up to 6.5 AMA PRA Category 1 Credits™ for each day of participation. In addition, each day of the workshop meets AAPC guidelines for 6.5 continuing education units.
The ACS will offer the following five remaining coding workshops in 2018:
Chicago, IL, April 12–13
New York, NY, May 17–19
Nashville, TN, August 9–10
Chicago, IL, November 1–3
The ACS also will offer a three-day course, including a day devoted to trauma and critical care coding at the New York City and (November) Chicago workshops.
Register for a course at www.karenzupko.com/workshops2/gensurg-workshops/. For more information about the 2018 ACS coding workshops, visit the ACS website www.facs.org/advocacy/practmanagement/workshops or e-mail
Registration is open to attend an American College of Surgeons (ACS) 2018 General Surgery Coding Workshop. With Medicare and third-party payor policy and coding changes taking effect this year, it is imperative that surgeons have accurate and up-to-date information to protect their reimbursements and optimize efficiency.
During the coding workshop, you will learn how to report surgical procedures and medical services and will have access to the tools necessary to succeed, including a coding workbook to keep for future reference with checklists, resource guides, templates, and examples. Physicians receive up to 6.5 AMA PRA Category 1 Credits™ for each day of participation. In addition, each day of the workshop meets AAPC guidelines for 6.5 continuing education units.
The ACS will offer the following five remaining coding workshops in 2018:
Chicago, IL, April 12–13
New York, NY, May 17–19
Nashville, TN, August 9–10
Chicago, IL, November 1–3
The ACS also will offer a three-day course, including a day devoted to trauma and critical care coding at the New York City and (November) Chicago workshops.
Register for a course at www.karenzupko.com/workshops2/gensurg-workshops/. For more information about the 2018 ACS coding workshops, visit the ACS website www.facs.org/advocacy/practmanagement/workshops or e-mail