As the 112th Congress prepares to debate health reform once again, the opportunity arises to reflect on the impact the Patient Protection and Affordable Care Act (ACA) may have on the field of surgery. Now it is time for surgeons to get involved and make a difference in Washington, D.C., through advocacy, hard work and courage. As a general surgeon practicing at the University of California, San Francisco Medical Center, I will share my personal recommendations for the future of surgery following the implementation of ACA.

I’d like to begin by talking about the priorities of the American College of Surgeons (ACS). The ACS was extensively involved in the health reform debate, and favored the House’s version of the bill over the Senate’s. The Senate bill eventually passed, and the ACS now intends to move beyond the acrimony of the health reform debate and work constructively with Capitol Hill to implement the provisions of the bill.

The ACS’s executive director David Hoyt, MD, FACS, summarized the organization’s intent in the Bulletin of the American College of Surgeons (2010;95:4-6): “ACA is the blueprint for a whole new care delivery system … it is up to us to do everything that we can to make sure that the final structure is sound and equitable for surgeons and patients.”

Dr. Hoyt and the leadership of the ACS’s Division of Health Policy and Advocacy have been working tirelessly to enlighten the federal dialogue with a surgical perspective and have prioritized the following areas of the Act: 1) reforming payment models; 2) fixing the sustained growth rate formula flaws; 3) creating accountable care organizations; 4) introducing the Center for Medicare and Medicaid Innovation (CMI); 5) testing innovative payment methods such as bundling; and 6) ensuring that pay for performance initiatives, such as the National Surgical Quality Improvement Program, are grounded in rigorous data collection methodologies.

Concerns About the ACA

For surgeons across the United States, the ACA raises a number of important concerns. The law seeks to expand coverage to 32 million Americans. This expansion would cause physician workforce shortages to become worse in the future, overwhelming an already struggling health care delivery system. ACA does not provide a solution for the Sustainable Growth Rate. As a result, many surgeons are considering dropping out of Medicare, and many are doubtful that an expansion of Medicaid will be sufficient to deliver optimal and timely patient care. Although rural surgeons benefited from a small increase in support and a redistribution of residency training slots for general surgery, many surgeons remain concerned that the medical home will likely raise overall health care costs.

In an opinion article published in the San Francisco Examiner, former Massachusetts Department of State Treasurer Timothy Cahill expressed additional concerns about “RomneyCare,” on which the ACA was based: “No other program has grown faster … and ripped a gaping hole in the commonwealth’s budget. When universal coverage was sold to voters in 2006, they were told that it would cost about $88 million each year. The true cost to cover a mere 4% more was more than $4 billion.”

Surgeons and physician groups also have expressed major concern about a little-known provision of ACA, which will create a “value index.” According to the provision, “Quality of care is to be evaluated on a composite of risk-adjusted measures of quality established by the Secretary [my emphasis], such as measures that reflect health outcomes. Costs, defined as expenditures per individual, are to be evaluated based on a composite of appropriate measures of costs established by the Secretary that eliminate the effect of geographic adjustments in payment rates and take into account risk factors ... and other factors determined appropriate by the Secretary.”

The ACA contains hundreds of provisions like this, which were slowly released to the public after the bill had been signed into law. The difficult task of implementing these provisions has been delegated to the Secretary Kathleen Sibelius, a former insurance commissioner and governor, who will need expert advice and stakeholder input to truly succeed in fulfilling this challenge.

Misunderstood Surgeons

But perhaps what has surgeons most concerned are comments President Barack Obama made in 2009. On July 22, President Obama said: “[If] your child has a bad sore throat, or has repeated sore throats, the doctor may look at the reimbursement system and say to himself, ‘You know what? I make a lot more money if I take this kid’s tonsils out.’ ” And a month later at a town hall in New Hampshire, President Obama said: “Let’s take the example of diabetes … if a family care physician works with a patient to help them lose weight, modify diet, monitors whether they’re taking their medications in a timely fashion, they might get reimbursed a pittance. But if that same diabetic ends up getting their foot amputated, that’s $30,000, $40,000, $50,000—immediately the surgeon is reimbursed.”

Surgeons across the country were baffled by comments such as these, which signal the president’s profound misunderstanding of how medical care is financed and how hospital charges came to be. The California Medical Association responded by expressing deep concerns: “In the first example, [President Obama] stated that surgeons make $30,000 to $50,000 to amputate a foot of a diabetic. This assertion is false. Medicare pays surgeons $589 to $767 for a foot amputation. Medi-Cal pays $420 for the same. Hospital and other associated costs may add up to the greater amount, but it is incorrect and misleading to suggest the surgeon’s costs are responsible for that figure. In the second example, the president suggested that physicians take out children’s tonsils to make more money. This implication is inaccurate and offensive.”

L.D. Britt, MD, MPH, FACS, chair of the Board of Regents and ACS president, also responded: “President Obama’s unfortunate remarks during his July 22 press conference in which he suggested that a physician’s decision to remove a child’s tonsils—or any other procedure—is based on making ‘a lot more money,’ was ill-informed and dangerous. We were dismayed at this characterization.”

Despite the responses from the fields of medicine and surgery, President Obama never issued a clarification or an apology. Consequently, doctors across the country felt frustrated, as if they were not being heard or their perspectives were misunderstood or being misrepresented. As the reform debate evolved, many physicians began to feel as if the president were following the script for success from David Blumenthal, MD. Dr. Blumenthal has examined the presidents over the past 60 years who succeeded or failed in their efforts to pass massive health care legislation. In his book “Heart of Power,” Dr. Blumenthal detailed the strategy for success: 1) have passion; 2) speed; 3) bring a plan with you; 4) hush the economists; 5) go public; 6) manage Congress; 7) forget the professional standards review organization; and 8) learn how to lose.

(Mis)Framing Health Care

In the rush to speed the ACA bill into law, I am concerned that several key problems in health care were framed incorrectly. English political writer Earnest Benn expressed this point well: “Politics is the art of looking for trouble, finding it everywhere, diagnosing it incorrectly, and applying the wrong remedies.”

Amid the health reform debate, we have forgotten some of the amazing successes of the American medical system. According to a 2000 report from the World Health Organization (WHO), which ranked the U.S. system 15th in the world, 40% of the world’s medical tourists travel to the United States for care. The United States is first or second in kidney, liver and heart transplants; knee replacements; coronary artery bypass grafts; and angioplasties. American physicians can boast the shortest waiting time for elective surgery and the highest breast, colon and prostate cancer survival rates in the world. Doctors from the United States also have been awarded more Nobel prizes than those in all other nations combined.

Despite these successes, it is the second WHO report, released at the same time, which politicians and critics of the American health system cite most frequently. This report ranked the United States 37th based on an artificial construct of “potential performance” and used a flawed methodology to determine the placement.

Christopher Murray, MD, director of WHO’s Global Programme on Evidence for Health Policy, made a critical insight from the 2000 report, which was rarely discussed by the media or health reform debaters: “Although significant progress has been achieved in past decades, virtually all countries are under-utilizing the resources that are available to them. This leads to large numbers of preventable deaths and disabilities; unnecessary suffering, injustice, inequality and denial of an individual’s basic rights to health. The poor are treated with less respect, given less choice of service providers and offered lower-quality amenities. In trying to buy health from their own pockets, they pay and become poorer.”

This lack of fairness represents the fundamental problem in health care worldwide. In the United States, this issue is reflected in the skyrocketing number of bankruptcies due to medical expenses. One study compared variations in spending among the “U.S. News & World Report Top 10 Hospitals” in America for patients receiving end-of-life treatment. Cedars-Sinai Medical Center in Los Angeles topped the chart, spending an average of nearly $77,000 per patient, whereas Mayo Clinic in Rochester, Minn., and Cleveland Clinic in Ohio, were at the bottom, spending less than half that amount (around $36,000) [citation]. This finding led noted Princeton economist Uwe Reinhardt to ask, “How can the best medical care in the world cost twice as much as the best medical care in the world?”

Another study published in Health Affairs explored the forces contributing to the rapid growth in hospital expenditures, questioning whether this increase in spending was the result of population growth or complexity of conditions caused by aging. The researchers concluded that 30% of rising health care costs is caused by excess hospital price inflation.

This inflation information will be useful. An inpatient room is $5,189, an intensive care unit bed is $17,500 and a computed tomography scan is $5,100. Daily labs are about $1,000, an endocatch bag is $505, three versastep ports are $831, an L hook is $214 and a clip applier $762. The prices of antibiotics vary. For instance, Cipro is $2 per pill, while Zosyn is 600 times more expensive, but is likely not 600 times more effective.

For many of these products, I am quoting actual charges my uncle received after his hospital stay in 2009. He was uninsured and was responsible for paying about 40% of these costs, resulting in his financial bankruptcy—a double whammy of catastrophic illness in America.

The ACA failed to directly tackle these cost concerns or the complex issue of caring for undocumented immigrants, often cited by hospitals as a primary reason for cost shifting and the high price of medical care. The ACA also imposed a blunt flat tax on medical device manufacturers but not on hospitals that sell devices and profit from a significant markup with no tax burden. In the end, the key next step for America is not to bend the “cost curve,” but to bend the “price curve” through greater transparency in hospital charges.

Addressing Medical Liability

When asked why medical malpractice reform is missing from the debate, the most frequent response, according to Harvard economists, is that the cost of jury awards and legal settlements from malpractice litigation are just “a drop in the bucket” compared with overall health spending, which reached $448 million in 2001.

But what about medical product liability? My colleagues and I regularly see startling headlines like “Medtronic Settles Heart Device Suits for $268M,” which highlights to me that looking at medical malpractice alone is insufficient and true legal reform has been missing from the ACA. Massive settlements from malpractice suits drive up the prices of devices and make me wonder whether class action suits are the most cost-effective and equitable way to compensate patients when they are harmed without hampering advances in medical education. Perhaps the next important step is to transform our legal system into a more timely, efficient, cost-effective and equitable industry.

Forward, Sideways or Backward?

I am often asked whether the ACA represents movement forward, sideways or backward. My answer is that depending on which part of the ACA you look at, it represents movement in all three directions at once.

But I am hopeful and optimistic for the future because I think we are now at the beginning of a critical venture to improve our health care system. Most importantly, as our nation moves forward in health care reform, we will need to integrate physicians into the discussion to make the reform meaningful. The ACA represents a first step toward this end.

As we enter the next phase of a “health care revolution” in America, I believe that the essential next steps include reforming our unique employment-based health care insurance, increasing patient responsibility, reconnecting the payer and recipient of care and integrating the voices of physicians and Congress. With 17 doctors in the House and three in the Senate, I believe that important progress can be made working in a bipartisan manner with elected officials to advance the central vision that “health care is a public good,” and to promote justice, equality and financial fairness in the American health care delivery system.