Special article

Socioeconomic activism in a changing medical workplace

Josef E. Fischer, M.D.*Department of Surgery, Beth Israel Deaconess Medical Center, 110 Francis St., Boston, MA 02215, USA

Manuscript received September 4, 2002; revised manuscript September 7, 2002

Abstract

The House of Medicine has been disadvantaged by not being at the table, by believing that society will take care of us, and by believingthat economics are not critically important to the practice of medicine. All of these assumptions are incorrect. We must be at the table thenext time around and we must be prepared for the crisis of access that will bring about societies’ dealings with these important issues. ©2003 Excerpta Medica Inc. All rights reserved.

Keywords: Reimbursement; Medicare; Patient access; Emergency Medicare Treatment and Labor Act

I have known George Sheldon, in whose honor thisFestschrift is being held, since the late 1960s or early 1970s.We have been good friends for a long time. To a certainextent George has been an intrinsic part and a help to mycareer. Indeed our careers have been to a certain extentparallel. It is really a pleasure to speak at this Festschrift.

The beginning of socioeconomic engagement

I would imagine that if one goes back to the evolution ofthe socioeconomic activities of American Surgery, particu-larly general surgery, one must go back to the early 1980swhen Medicare began to engage with Dr. Tsiao of theHarvard School of Public Health. Prior to that general sur-gery had been absent and had been extremely quiescent asfar as any involvement in socioeconomic areas. Generalsurgeons, I suppose, were still the last “compleat physi-cians,” taking total care of their patients. So long as theywere allowed to operate on and care for their patients andthe workload was not too much of a hassle I think mostgeneral surgeons would be happy operating on and takingcare of patients. Indeed, with regard to Blue Cross and BlueShield and fee setting, general surgeons were notable bytheir absence. Whereas, the orthopedic specialties placed anorthopedic surgeon on every board that was determiningfees which helps explain some of the differences in fees that

exist to this day, general surgeons were conspicuous by theirabsence.

In engaging Dr. Tsiao and the Harvard School of PublicHealth, the Health Care Financing Administration (HCFA)knew that the methodology was never intended to be usedfor reimbursement. However, it was available and theHCFA decided to take advantage of it. I got involved in thisarea about the mid to late 1980s at which time surveys werebeing done as to the amounts of time that were being carriedout for certain procedures, obviously to be used as a com-ponent of reimbursement. Here again, the general surgicalcommunity completely misunderstood the purpose of thesurveys. Testosterone ruled rather than common sense. Peo-ple who could not even get through the abdominal wall in30 minutes began to put down times of 90 minutes for a lowanterior resection. Indeed, individuals thought they wereadvertising their own skills and minimizing times ratherthan putting down accurate times. I personally remember asituation in which a group of us were sitting at the Wash-ington office of the American College of Surgeons, review-ing these surveys as to their veracity and one of the mem-bers of the committee said openly that he never took morethan 40 minutes for an inguinal hernia. I asked his permis-sion to call his operating room and ask the operating roomif they had data concerning this gentlemen’s last 50 herniasand what the median time was. They responded that it was64 minutes. That was what I told him and he was shocked.That was a good example of how we deliberately, it seems,underfunded our reimbursement.

Regardless of what the methodology was, as it was* Corresponding author. Tel.:�1-617-632-9770; fax:�1-617-632-9701.E-mail address: jfische1@caregroup.harvard.edu

The American Journal of Surgery 185 (2003) 6–9

0002-9610/03/$ – see front matter © 2003 Excerpta Medica Inc. All rights reserved.PII: S0002-9610(02)01139-X

reconstructed subsequently, and as we in the College laterengaged some of the consultants that were used by Tsiaoand HCFA at that time, it was clear that the methodologywas intended to penalize surgeons. To put it kindly it mayhave been disingenuous, but perhaps bordered on the fraud-ulent. In any event the damage was largely done and generalsurgery has been playing catch-up ever since.

General surgery could not even generate the interest tohelp write the C.P.T. codes initially. It is alleged that theC.P.T. codes were largely written by a plastic surgeon. Incontrast, the other surgical specialties concentrated on theC.P.T. codes and getting adequate C.P.T. codes for thedeclinations of various procedures as well as obtainingadequate reimbursement. This was true of most of the spe-cialty academies with which the socioeconomic area re-mained a very prominent part of their activities.

The American College of Surgeons belatedly began toengage in these activities. However, the College represent-ing general surgery had heretofore been almost entirely aneducational and scientific organization and it required amajor change in direction for such alterations to take place.This was carried out at the important regents’ retreat of1985 at which it was decided to establish a socioeconomicdepartment and to begin to engage in socioeconomic rep-resentation of the Fellowship. My own initiation into thisarea of the College began shortly thereafter at the behest ofGeorge Block and Alec Walt from the College. WardGriffen, at that time the Executive Director of the AmericanBoard of Surgery, with Alec Walt and George Block con-stituted a triumvirate that supported the survival of generalsurgery.

When I joined the College’s effort, Isidore Cohn hadtaken on the responsibility of C.P.T.’s and George Blockrecruited John Gage, Frank Opelka, Skip Collicott, myself,and others to begin with, to carry the load in what laterbecame the Coding and Reimbursement Committee of theCollege. Much of the damage had already been done and itwas our task to try to undo what had happened to generalsurgery. For a time we were successful. We brought forthmany new codes, did surveys and with Gage and SkipCollicott at the Relative Value Update Committee weresuccessful to a certain extent in updating the fee schedule.Most of us knew that while we were participating that thiswas going to be not just for Medicare, but that ultimately allpayment was going to be based on Medicare principles andreimbursement. Therefore, we were basically dealing withreimbursement for the entire general surgery. Initially, wemade a great deal of progress. Bart McCann was the Med-ical Director of HCFA and determined what we were doingand thereby initiated the concept of budget neutrality byfamily; that is if we put forth a new code for something thatwe felt was more complicated this was going to have tocome out of the overall payment per family and the value ofthe more common every day procedures would fall. Thisacted as a damper on our efforts to try to upgrade payment.Ultimately, the concept of overall budget neutrality was

probably the only area in the United States in which theabsolute and relative payment throughout a decade, which,although a period of relatively low inflation, nonethelesshad increasing prices for services and the cost of labor.

Problems multiply

Most of us who entered the process entered it in the effortto try to help, however, we rapidly became disillusioned bythe cynicism and sometimes the underhandedness that ac-companied the entire area of reimbursement and HCFA.How many of you remember the issue of “overpriced pro-cedures” such as gallbladders and hernias? This was simplya one time, or perhaps more than one time since it waspermanent, decrease in fees for gallbladders and herniassimply because HCFA thought they were paying too muchfor them. What does overpriced procedures mean? Who saidso? Surgeons took this in stride and there was no revolt asthere probably should have been. However, for those of uswho were working in the area the cynicism and the desire topay physicians less, which seemed to be all we could seewith HCFA, began to take its toll. Those of us who werewell intentioned, perhaps slightly idealistic, quickly becamedisabused of this. Indeed as one high official of HCFApersonally told me “ I don’ t know why you guys continue towork with us and trust us. We lie. We cheat. We steal. Wetell you one thing and we do another. I am surprised you stillwork with us at all.”

In the early 1990s culminating in 1994 the hypothesiswas finally sold to HCFA that primary care was the answerto the nation’s health ills, that prevention, wellness and theavoidance of late procedures were the way to go. Congressbasically stated its intention to redistribute income fromproceduralists to primary care. Thus HCFA was able to setthe houses of medicine against each other. The issue ofpractice expenses then emerged. Paul Ebert proposed thatwe should forget about practice expenses and keep the twoconversion factors but failed to get a hearing. I representedthe American College of Surgeons in one of the principalpractice expense committees and it was clear when I walkedinto the room that it had already been decided. The workinghypothesis was that surgeons didn’ t need an office whenthey were in the operating room. Also, that their nurses whohelped them and made rounds with them were not to beincluded as part of direct expense. The entire exercise wasa sham. Further insults followed. The Emergency MedicareTreatment and Labor Act (EMTALA), originally conceivedas an unfunded mandate, was abused as hospitals undertookmergers, especially in rural areas. Hospitals that were sep-arated by 50 miles could then, for example, put two neuro-surgeons, the only neurosurgical group in the rural area, oncall on both hospitals.

This evolved thus to the current status of medicine. Wefind a medical system previously quite good, perhaps notperfect, especially with the care of the indigent, which is

7J.E. Fischer / The American Journal of Surgery 185 (2003) 6–9

totally dispirited, a sullen, demoralized work force, which ishaving difficulty in attracting its successors with resourcesof physicians offices being stretched to the breaking point.In various surveys of various physicians and especiallysurgeons four issues constantly are seen, including in noparticular order:

1. The malpractice crisis with premiums going up at analarming rate.

2. The inability to meet practice expenses as they arearbitrarily cut continually.

3. Inadequate reimbursement.4. The hassles of dealing with HMOs.

With respect to Medicare I had long predicted a crisis ofaccess in which, as payments became more and more inad-equate (witness the 5.2% cut in reimbursement this year)that Medicare patients were going to begin to have difficultyin getting appointments. Twenty-four percent of physiciansnow admit and probably there are many more that do notadmit it, that they keep Medicare patients waiting to getappointments or refuse to see any new Medicare patients orfor that matter any new patients above the age of 60. Crisesof access are going to extend to all insured patients. Physi-cians are leaving practices and setting up “boutique prac-tices” in which they require a retainer of anywhere between$1,500 and $20,000 per family. In exchange they will limittheir practice and take enough time with patients to treatthem as they should be treated. The decreased number ofapplicants to medical schools, the residents leaving medi-cine after completing their residencies (especially at goodinstitutions) the unfilled places in general surgery, the“pushback” with hospitals banding together and physiciansbanding together and refusing to take contracts all witness acrisis that is upon us.

By next year with further cutbacks in Medicare I predictthat 50% of physicians will be refusing to take Medicarepatients—at which point the four-letter word that terrifies allCongressmen, the AARP, will come into play and Con-gressmen’s phones will be ringing off the hook.

Medicare patients are not the only ones experiencing acrisis in access. Costs are skyrocketing. Managed care or-ganizations did not manage care—all they did was managethe cost. The Ponzi scheme of using additional enrollmentsto hold down the premiums is now over and premiums aregoing up at 15% to 20% annually as their inefficiencies geteven more striking. We have been told that it will takeapproximately 130 billion dollars to fix Medicare over thenext 10 years and it will not fix it entirely. The fix thatMedicare envisions is probably not enough for most physi-cians and it is unlikely that most physicians will, even at thatpoint, take Medicare patients.

George Sheldon has played a major role trying to fightthis. He has been at the center of the activities of theAmerican College of Surgeons, various other national or-ganizations, and serving as President of the AAMC. He haspushed repeatedly, in addition to the scientific and educa-

tional side of the College for there to be a socioeconomicside to what the House of Medicine does. He was a memberof a select committee of five which helped organize theHealth Policy Steering Committee, which one of its accom-plishments was to change the structure of the College for thefirst time since 1913 so that a 501 (c) (6) could expand someof the socioeconomic activities of the College and found aPolitical Action Committee. The College has determinedthat it needs some help with its activities and that lobbyingwas perfectly appropriate for its fellows.

Where do we go from here?

Where are we?

Physicians and surgeons are in open revolt in the coun-try. As this country only responds to crises, our initial goalshould be restoring the House of Medicine and unifying it.With respect to surgery it is my hope that the College willserve as the “mother church” of all of surgery and we willbe able to speak with one voice. After that we will have tojoin forces with the other nonsurgical specialties.

What we want

Since this country only responds to crises and it is mybelief that the crisis will be upon us within the next year ortwo, we should be prepared to state what it is we want fromany negotiations that will take place. They include thefollowing:

1. The ability to take care of our patients properly.Practice expenses must be realistic and must include,for surgeons at least, the salaries of nurses whoaccompany us on rounds and even in the operatingroom be included as direct, not indirect expenses.

2. We must get paid properly in our office expenses sowe can hire nurse practitioners who will answer thephones and answer patients questions about theiroperative procedures as well as their medicationspromptly.

3. The malpractice insurance expense of CMS reim-bursement must be appropriate, correct, and updatedand for that particular area. A common trick byHCFA, now CMS, is to take the malpractice expenseat a nearby, but rural area, as compared with the cityin which such malpractice expenses are beingjudged. The geographic adjustment, the so-calledGPSI, is never accurate nor is it timely. It is mybelief that once CMS starts paying for accurate up-dates on malpractice expenses we will not need tortreform. Once the practice expense of accurate mal-practice costs, which are skyrocketing, are under-stood by CMS, the Feds will rush to enact tortreform.

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4. Modification of EMTALA so that it is paid and sothat HMOs and hospitals that merge cannot put in-dividuals at a disadvantage by having to take care ofpatients who may be 50 miles away. Individualsmust have the opportunity to choose the site of theirpractices and the nature of their practices so thatpractice is not unreasonable, and is possible.

5. We must have time to communicate with other phy-sicians and to prepare appropriate consults and in-volve other consultants. Tricks like paying EMcodes on a single day for a given group, such as iscurrently happening in Massachusetts, are inappro-priate and against the patient’s best interest.

6. Having a single form for insurance companies sothat we don’ t have to fill out several different forms(there are 1,500 at the present time) for each patient.

7. Reimbursement that provides us with enough capitalto keep up with technology. Medicine has not ben-efited from information technology partially due tothe fact that there is not enough capital to invest inthese expensive innovations, but which are basicallywork saving.

8. Enough capital to carry out our office practices inpleasant, appropriate surroundings and no more un-funded mandates.

9. No more unfunded mandates.10. Reasonable updated mechanisms, which are realis-

tic, and are not gimmicks so that the Federal gov-ernment can underpay us, particularly the “behav-ioral adjustment,” which is a sham. This innovationproposes that physicians will see more patients if theprice is cut. That needs to be disposed of.

11. The return of two conversion factors, so that utili-zation can be more easily tracked.

The House of Medicine

The line in the sand has now been crossed. Physiciansnow cannot afford to send their children to the schools thatthey once attended. Physicians are bad-mouthing medicineand we are unable to renew our work force for the verysimple reason that we keep on telling our children andanybody who will listen, that medicine is not a proper

profession to pursue. My belief is that since this countryresponds only to crisis, that despite Dr. Sheldon’s seminalwork in the work force, and his repeated studies of extraor-dinarily high quality of what our work force will be that wedo nothing to improve the lot of individuals to whom accessis a crisis. It is unfortunate, this is not in keeping with mycalling, nor with the Hippocratic Oath, nor in the way I wastrained. However, I do not believe that this country willrespond to anything else but a crisis of access. When thatcrisis of access will come, probably next year, we need to beprepared. We can no longer be passive. We must have a spotat the table. We must indulge in collective bargaining andwe must have the ability to decide on our own fate andparticipate in it. Failing that, the destruction of the medicalsystem will be complete.

The changes in medicine over the past decade, whichhave been extraordinarily destructive, are the results ofsocietal decisions. They cannot be fixed by medicine itself.There must be societal attention and there must be sufficientresources to enable physicians to participate in their ownworking conditions. The cynicism and greed that has char-acterized corporate attention to medicine over the past de-cade must come to an end. Patients are being disadvantagedand abandoned by our current system.

The House of Medicine has been disadvantaged by notbeing at the table, by believing that society will take care ofus and by believing that economics are not critically impor-tant to the practice of medicine. All of these assumptions areincorrect. We must be at the table the next time around andwe must be prepared for the crisis of access which will bringabout societies’ dealings with these important issues. I findit particularly unfortunate that it has come to this, butsometimes, good things come out of bad situations.

The time has come to put the patient first; to rid thesystem of greed, cynicism, and destruction. Gross corporatesalaries, the games the HMOs play, the inefficiencies of thesystem that takes up to 21% for administrative costs, mustbe totally changed. The time for the revolution is now—andthe revolution must be revolution in the way physicians aretreated. It must be patient centered. If that does not occurthen this country’s medical system, already in a great deal ofdifficulty, is doomed.

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