Editor’s Note: Below is the transcript of a recent interview of Thomas Russell, who is stepping down on January 1 after ten years as executive director of the American College of Surgeons, by John Iglehart, Founding Editor of Health Affairs. In a wide-ranging and provocative interview, Russell endorses the creation of an independent Medicare commission to better allocate health care resources and contain costs. He also expresses skepticism about “scope of practice” laws that restrict the activities of nonphysician providers such as advanced nurse practitioners. In some instances, these restrictions are “a waste of energy,” he states. “If someone’s competent and trained to perform certain clinical services, they should be permitted to provide them, particularly in workforce shortage areas and specialties.”
Russell observes that “physicians are constantly faced with the dilemma of whether to try to meet society’s demands and be responsible stewards of resources or to meet the individual patient’s specific demands.” He continues: “But I think that as we bring the public along and as physicians educate themselves, we’ll all gain a better understanding of the fact that the money available for health care is finite, and we have to learn how to allocate it more appropriately. This way of thinking is becoming more common among younger physicians and surgeons, and is being approached didactically in residency.”
In surgery, Russell says, “there’s a lot that we could do differently to help bend the curve. For example, we’re probably doing more screening than is medically necessary, and reducing the number of tests we do on low-risk, healthy patients would save money. We also need to look in a very thoughtful, ethical way at rational — I’m not using the word rationing, I’m using the word “rational”–ways to improve end-of-life care.” Russell cites the need for medical and surgical professions to develop policies about when scans, such as a CTs and MRIs, are indicated, and he calls for “standardized ways of treating diseases so that every health care professional involved in coordinating a patient’s care is addressing the condition in the most cost-effective way that follows the scientific evidence.”
Russell also addresses workforce issues, particularly the need for more general surgeons in rural and other underserved areas. But “before we start opening up lots of new medical schools and throwing more money at graduate medical education,” he urges policymakers to think carefully about what the workforce of the future should look like: “As I look back on my 35 years of practice, I can tell you that there are a lot of things we were doing that are now clinical relics of the past. Surgeons are doing hundreds of thousands of bariatric surgery procedures today; demand is pumped up because the procedure is advertised directly to the public … But, are we going to be doing these operations in 10 or 20 years? Is surgery still going to be primary means of treating pathological tissue in the future, or will some new competing technology or medical discovery render these types of operations unnecessary?”
John Iglehart: You have undoubtedly heard many physicians say, “I certainly would not advise my children to pursue a medical career today.” Do these individuals represent a tiny minority of the profession or is that a growing sentiment among physicians?
Thomas Russell: I don’t view it as a growing sentiment. Many physicians don’t like the way things have gone in terms of health care financing and other socioeconomic aspects of medicine, and so that prompts them, in a state of frustration, to ask, “Why would anyone ever go into medicine today?” But I think a lot of physicians really like what they’re doing. I certainly did, and as you know, I have a daughter who just finished medical school, and she is very excited about her future. Pursuing a medical or surgical education is a lengthy and very expensive process, but we’re rewarded for those investments by being able to be part of a wonderful profession.
Surgeons and quality improvement programs
Iglehart: Since publication in 2001 of the Institute of Medicine’s landmark study Crossing the Quality Chasm: A New Health System for the 21st Century, policymakers, providers, payers, and patients have become increasingly interested in improving quality and patient safety. Where would you place surgeons on the continuum of concern over quality and safety?
Russell: The IOM’s release of its series of reports on medical errors, quality of care, and patient safety represented an opportunity for the American College of Surgeons (ACS) to return to its roots of serving as a standard-setting organization for surgery and to redirect its efforts toward addressing these issues. Quite frankly, we are sponsoring programs today that we could not have undertaken a few years ago—evaluating surgical outcomes, evaluating surgeons, and evaluating facilities in which surgery is done—because our members were more concerned about other matters. So I would say the ACS has undergone a sea change in terms of the kinds of programs in which we engage since the IOM began releasing these studies.
Iglehart: How does the ACS measure progress in these various programs that you mention? What would you score as a success, say, if you were asked by a member of Congress?
Russell: We now have about five years of experience with one of our programs that measures risk in relation to a patient’s outcome—the National Surgical Quality Improvement Program (NSQIP). This program is beginning to yield data about outcomes, complications, and mortality in hospital settings that could be pieced together to give a member of Congress and the general public a good picture of what seems to work and what doesn’t. But this kind of research is difficult to conduct. It takes a long time to produce results, and it has never been done at this level before. So, it’s going to take awhile to develop accurate measures that are reliable, risk-adjusted, and based on valid clinical data and then take that information and formulate deductions that will be useful and understandable to non-clinicians.
Iglehart: I would assume that more than a few surgeons regard such activity as an intrusion into the independent practice of medicine. Is there a generational difference among surgeons in their willingness to cooperate or at least participate in these kinds of initiatives?
Russell: Absolutely. The younger surgeons have trained in an environment in which they to expect that the quality of care they deliver will be measured and evaluated, so they don’t really have any difficulty participating in these activities. It’s some of the older physicians who entered practice in a more autonomous era who struggle with these new forms of oversight.
Surgeons and physician payment reform
Iglehart: Reforming the system of health care delivery and financing is on the front burner in Congress, as you know. What is the surgical community’s position on reform, and what do you regard as the single most important change you’d like to see come out of reform?
Russell: First, let me say that the surgical community is not homogeneous, and they’re all over the map on reform. The College has a split membership. Some surgeons think that the status quo is just fine and that greater oversight and accountability are unnecessary. They view them as intrusions into the autonomy of a sovereign profession, while others are all in favor of reform.
There is at least one matter on which I think we mostly agree, and that is the fact that we have to do something to fix our broken payment system. So, the number-one change that I would like to see emerge from the health care reform debate is fundamental, long-term improvement in how physicians are paid, so that they really are being paid for providing cost-effective, high-quality services. The system needs to move from one that offers incentives for providing more services to one that rewards the provision of services that result in better patient outcomes and more effective use of our resources, which means value. Physicians should be paid based on these measurements, and those who provide high-quality care should be paid well. I think that’s a fundamental change that needs to occur.
Iglehart: Would that mean, according to your vision, an abandonment of the fee-for-service payment model and going to an alternative model, or some kind of a hybrid?
Russell: I recently addressed a large group of surgeons and asked them whether they are paid a salary, and most of them raised their hands. Throughout the nation, more surgeons are becoming salaried professionals. Most academic surgeons as well as those in integrated delivery systems—such as the Mayo Clinic, Geisinger, Kaiser, and many others, including Veterans Affairs—are on salary. So are doctors who are employed by the VA. I think it’s safe to say that more than 50 percent of the nation’s physicians are paid a salary. And, some of the happiest doctors whom I’ve met are the salaried ones because they don’t have to deal with the hassles of malpractice insurance, including the high premiums they pay, or coding, or any of the other administrative burdens that confront physicians who are in private practice and reimbursed through the complicated fee-for-service system.
More and more young physicians just entering practice don’t want to hang up a shingle as a solo physician. They want to join an established group and work a predictable schedule that permits a comfortable lifestyle, and at the end of the month they want a check.
Now, there will always be a pluralistic way of practicing medicine in the United States. Besides fee-for-service, there will be bundling of payments for services and perhaps gain-sharing. So it will be a hybrid model. But I think a significant number of physicians will earn a salary and will be satisfied with a more balanced lifestyle.
Iglehart: Surgeons are often paid on a per episode basis that includes pre- and postoperative care, as well as the procedure itself. Could one assume, then, that they would not be uncomfortable with the bundling of payments that is being discussed by policymakers?
Russell: Exactly. Nonetheless, there will always be physicians who don’t want to move from the fee-for-service model. They want to continue to be paid for each service rendered. As a result, when a patient leaves a hospital, he or she has a shoe box full of bills. But in more mature, integrated systems, the bundling of payments already works quite well. The hospital bills for all the services and the charges are divvied up on the basis of the contracts that the physicians and other providers have with the network.
Best ways to slow health spending
Iglehart: In the context of the reform debate, President Obama has emphasized as an imperative what he calls “bending the cost curve.” What are your thoughts about the best ways of slowing the growth of health care expenditures, assuming you believe that they must be slowed?
Russell: I absolutely believe they must be slowed. Otherwise, health care is going to drive the country into bankruptcy. The real question is, does the U.S. have the political will to do it. Slowing health care costs will involve efforts not only in the halls of Congress but in the house of medicine and in the patient population as well.
I feel very strongly that patients need to take more responsibility for their own health. I used to tell my patients, “You are your own best doctor.” It’s simply absurd for patients who have been setting themselves up for medical problems by smoking, overeating, or overdrinking for 50 years to expect physicians to reverse the health consequences of such behavior. We’ve got to empower patients to become better stewards of their own bodies.
Next, physicians must take a closer look at their practices and be certain that the services they provide add value, not just more work, which has driven a lot of people in the past. Indeed, all stakeholders, including the insurance companies, pharmaceutical companies, device manufacturers, and so on, need to focus on determining which products and services actually have a positive effect on quality of life and not just on their bottom line. In surgery, there’s a lot that we could do differently to help bend the curve. For example, we’re probably doing more screening than is medically necessary, and reducing the number of tests we do on low-risk, healthy patients would save money. We also need to look in a very thoughtful, ethical way at rational – I’m not using the word rationing, I’m using the word “rational”–ways to improve end-of-life care.
In addition, the medical and surgical professions need to develop protocols for the best ways to approach diseases. We need policies about when scans, such as a CTs and MRIs, are indicated, and to make sure they are not unnecessarily repeated by another physician. And we must develop standardized ways of treating diseases so that every health care professional involved in coordinating a patient’s care is addressing the condition in the most cost-effective way that follows the scientific evidence.
Iglehart: To me, you are suggesting that physicians must broaden their perspective in relation to the allocation of resources, no longer simply addressing the needs of the patients in front of them, but thinking in a broader societal context. Is that a change in direction that physicians might embrace?
Russell: I think they will at the mega level. The problem is that a practicing physician is confronted with the one-on-one reality of trying to help the specific patient in front of him or her. So, physicians are constantly faced with the dilemma of whether to try to meet society’s demands and be responsible stewards of resources or to meet the individual patient’s specific demands. But I think that as we bring the public along and as physicians educate themselves, we’ll all gain a better understanding of the fact that the money available for health care is finite, and we have to learn how to allocate it more appropriately. This way of thinking is becoming more common among younger physicians and surgeons, and is being approached didactically in residency.
Consumer-driven health insurance
Iglehart: When you talk about the responsibility of an individual to be mindful of their health – don’t overeat, don’t smoke, etc.—it brings to mind a drift that’s afoot in the insurance market. What is your view of the consumer-driven health insurance model that has high deductibles and is designed to make individuals more prudent purchasers of care by giving them, as the saying goes, “more skin in the game?”
Russell: I think it’s a very good idea conceptually, but it would not be right for everyone. The public must be educated about the implications of this model and become more medically literate. For instance, I think that the Number One way to help patients avoid frivolous trips to the ER is to educate them about where they should turn to receive appropriate care for nonemergency conditions and to make certain they have access to primary care physicians. Perhaps imposing stiff cost-sharing requirements would further discourage unnecessary trips to these settings, many of which are experiencing workforce shortages.
The health care workforce: now and in the future
Iglehart: The reform discussion has paid very little attention to the ability of the health care workforce to treat millions of more patients should uninsured individuals gain coverage. In relation to the surgical community, how do you characterize it in terms of its capacity to care for millions of newly insured individuals?
Russell: I think the short answer is there are shortages in some areas already, and physicians are maldistributed, with many more than are probably necessary practicing in the most attractive U.S. cities. Here’s how this maldistribution of surgeons has arisen. About 80-90% of medical school graduates who pursue surgery as a specialty begin their residency training in general surgery. After five or six years of residency, and at ages 32 to 34, many pursue additional training in a fellowship that will allow then to focus on just one type of disease or organ that general surgeons treat and operate on. That is to say, they become super-specialized in breast surgery, minimally invasive surgery, bariatric surgery, cardiac surgery, or cancer surgery. So they’re taking themselves out of the pool of professionals who can perform the broad range of general surgery procedures. And, most of this highly specialized surgery is performed in large cities, so these surgeons are not typically accessible to rural patients.
Young doctors are drawn to these highly specialized practices because the pay is better, and so is the lifestyle. But this trend has created a real problem for the profession and for patients. Very few people train to be general surgeons anymore, and that’s who many smaller communities really need. Like a wonderful family doctor told me a few months ago, “You give me a good general surgeon, and we can take care of 90% of the needs of the rural community in Indiana where I practice.”
Iglehart: Are there public policies that should be enacted to address this issue?
Russell: Absolutely, and it’s worth noting that both the House and Senate reform bills that would provide bonuses to primary care physicians and general surgeons who agree to practice in medically underserved areas. Loan forgiveness for students who have accumulated large medical school debts could also attract new doctors to underserved areas. In recent years, the government has encouraged the immigration of more international medical graduates by liberalizing the number of J-1 visas. I also believe it is important for government to keep closer track of health workforce trends, an activity it has long overlooked.
But before we start opening up lots of new medical schools and throwing more money at graduate medical education, we have to ask a very fundamental but difficult question: What are surgeons and other doctors going to be doing in 10 or 15 years? As I look back on my 35 years of practice, I can tell you that there are a lot of things we were doing that are now clinical relics of the past. Surgeons are doing hundreds of thousands of bariatric surgery procedures today; demand is pumped up because the procedure is advertised directly to the public. Those are the only procedures some surgeons perform. But, are we going to be doing these operations in 10 or 20 years? Is surgery still going to be primary means of treating pathological tissue in the future, or will some new competing technology or medical discovery render these types of operations unnecessary? These are the questions we need to be asking and thinking about when we are designing training programs and developing the workforce of the future.
Iglehart: It takes many, many years to train an internist and even more time to train a surgeon. What does the United States do in the meantime, if reform extends coverage to millions of newly insured people?
Russell: Well, I think that surgery will always be done by surgeons, at least in this country. But physician assistants are invaluable to surgeons. They relieve so much of the administrative workload and can document what we do in the clinical setting and on patient rounds. Many surgeons who practice in the sophisticated integrated systems that I spoke of previously are assigned physician assistants who are very instrumental in coordinating care, in many respects more valuable than house officers who keep rotating as part of their training. A physician assistant might work with a surgeon for years and know his or her every professional move.
Iglehart: I don’t know that it’s necessarily the case in the surgeon community, but there are fierce battles at the state level around scope of practice issues as applied to physicians, advanced nurse practitioners (APNs), and other allied professionals. Sometimes these battles seem to keep APNs from providing care that they are trained to provide because doctors fear their turf is being invaded. Are these battles worth the time and energy they consume– whether it’s prescribing drugs, providing primary care, or doing other things that they are presumably qualified to render to patients?
Russell: I think in some instances they’re a waste of energy. If someone’s competent and trained to perform certain clinical services, they should be permitted to provide them, particularly in workforce shortage areas and specialties. For example, if there is a shortage of primary care physicians and the profession can’t fill that void, it seems inevitable that allied professionals—APNs, physician assistants, and perhaps others—will fill it. However, the College maintains that operations must be done by individuals who are trained to do surgery. In short, due to its risks, surgery should be done by trained, board-certified surgeons.
Malpractice law and best-practice protocols
Iglehart: Ever since President Obama suggested in his health address to Congress an approach to dealing with professional liability issues, the subject has come to life in the reform dialogue. How big an issue is that for surgeons today, and how does the community propose to address it?
Russell: It is a huge problem for many surgeons, depending on their practice location and specialty. The specialties of OB/GYN and neurosurgery face particular challenges. High premiums of more than $100,000 a year for malpractice insurance are not uncommon for these specialists or for any physicians practicing in certain states, such as Florida. Furthermore, the risk of being sued leads physicians to practice defensive medicine, which adds costs to the health care system. Organized medicine and many Republican legislators have long argued in favor of capping awards for noneconomic damages, but I don’t believe the nation will ever reach a consensus on that proposal, although a few states have implemented the limits. I think instead more efforts should be made to educate, in this case surgeons, about how to avoid or better manage risk by staying within their scope of practice. Communication with the patient and his or her family throughout the surgical experience is also key to helping these individuals understand why there was a negative outcome. When a mistake is made, apologize, if you practice in a state that has passed legislation providing legal protections for saying, “I’m sorry.”
Very important, too, is for the profession to develop evidence-based best practice protocols and for physicians to follow them closely. In my era, we objected to this form of standardization and called it “cookbook medicine.” But, as calls for accountability have increased, lawmakers should consider setting policies that protect physicians who adhere to professionally developed protocols. In these cases, if a patient sues because of a bad outcome, the physician can respond with a legitimate defense: “Look, I followed the protocol that we all agreed was best practice. I’m sorry for the bad outcome, but a bad outcome does not equal malpractice.”
Commercialism in medicine
Iglehart: The past several decades have seen a rise of commercialism in medicine. For-profit enterprises have emerged in many forms of medical practice, including ambulatory surgical centers and specialty hospitals that physicians own or are invested in, general hospitals whose stock is publicly traded, and direct-to-consumer advertising that has driven greater use of pharmaceuticals. What’s your view of this trend of commercialism as it applies for physicians?
Russell: It presents medicine with an array of issues for which there are no easy answers. I often say that when the profession of medicine and the business of medicine intersect, some real ethical issues arise. Some physicians are very good business people. They recognize that other people in the health care sector are making a lot of money and don’t think they should be locked out of these opportunities, especially in an age when reimbursement is not keeping pace with practice expenses. I understand that and I’m respectful of their feelings, but I am also concerned that there have been some serious abuses. When physicians own or have invested in a specialty hospital or ambulatory surgery center and self-refer their patients to these facilities, I think that legitimately raises some red flags. When these facilities are operated ethically and well, they do bring advantages to patients—greater convenience, more efficient use of operating suites, good quality, and sometimes lower costs. But if rampant commercialism leads to abuses, such activities can also tarnish medicine and erode its ability to continue as a self-regulating profession.
The political influence of organized medicine
Iglehart: The number of organizations that speak for physicians in Washington today is greater than ever before, fragmenting the voice of medicine. What’s your view of the state of organized medicine today, when you think about it in terms of how it advocates for doctors before the government?
Russell: There are some real challenges for umbrella groups, such as the American Medical Association (AMA), an organization that represents about one-fourth to one-fifth of practicing physicians in all specialties. And, serving as an umbrella group becomes nearly impossible as more and more medical organizations recruit their own Washington lobbyists and pursue their individual and quite narrow agendas. Even within specialty societies, members are often all over the map politically. We have some members of the ACS who are extremely conservative, and then we have others who want a single-payer system. Here’s an example. The ACS joined the AMA in support of HB 3200, in part because it includes long-term Medicare physician payment reform that would eliminate the 21.5% scheduled reduction in fees that would take effect January 1, 2010, and further cuts in subsequent years. Although most surgeons like this idea, we got a lot of pushback from some of our members, mostly because the legislation also would establish a public plan, which they view as a gateway to a single-payer system.
Congress and the cost curve
Iglehart: Are you confident that Congress, as the body our founders created to represent the interests of the American people, is capable of making the tough choices necessary to, as they say, “bend the cost curve?”
Russell: I do have my doubts given the innumerable pressures legislators face and the enormous sums of money involved. It’s always easier for our elected representatives to expand coverage and programs than to say “No,” but society cannot afford all of these initiatives, particularly given the mounting national debt. The dilemma, it seems to me, is the absence of a sanctioned body that is capable of discussing tough issues, forwarding its recommendations to Congress, and giving legislators the power to vote either in favor or against those recommendations–up or down, without picking them apart. One approach that the Obama administration and the Senate bill have proposed calls for creating an independent Medicare advisory commission, the IMAC, composed of physicians and other experts. Many organizations, including the ACS, have some very real concerns that the IMAC would be composed of presidential appointees with no direct accountability to voters. Personally, I’m in favor of such a panel, if the people who serve on it are qualified to make sound payment decisions and have clinical expertise. I think we need such a body—and, again, this is Tom Russell speaking for himself, not as a representative of the ACS. If health care could be likened to a game, there are no rules, and nobody’s in a position to make the rules.
Congress has been reluctant to grant CMS (Centers for Medicare and Medicaid Services) the statutory authority and resources to run what amounts to—if it were a private corporation—probably the largest company in the world. It has not had a permanent administrator since Mark McClellan stepped down in 2006. Without a body that is empowered to make strong recommendations on how to better allocate resources, health care is just going to remain in the lap of politicians, and I don’t believe that they have the expertise and perhaps the political will to make these really tough decisions.
Vision for the future
Iglehart: To conclude, what is your vision of the future of the U.S. health care system?
Russell: There are two huge forces in play right now. One of them is the effort of the Obama administration and its Democratic allies on Capitol Hill to enact health care reform legislation. That clearly is the most prominent force at work today. The other force—every bit as important, in my view, but not the focus of public attention or even perhaps much concern—is the practice of medicine. A commentary written by Robert Brook, a physician who is recognized as a guru on the subject of health-care quality, in the Journal of the American Medical Association (September 2, 2009) notes, “Health care reform in the United States is likely to fail without fundamental changes in the practice of medicine.” Brook concludes that unless specific action is taken, “two decades from now policy makers, physicians, health care organizations, and the public will still be discussing health care reform…” I agree that without fundamental change in the way medicine is practiced, we have a stalemate.
All of the key stakeholders have an obligation to step up to the plate more forcefully than they have to date and to think beyond their self-interests. The medical profession in particular must be heavily involved because physicians make most of the resource allocation decisions, they are in the best position to determine best clinical practices, and they are the people to whom their patients turn when they are most vulnerable. This is our profession, and, thus, we have a profound obligation to improve an unsustainable system.