Addressing Long-term  Stability of Medicare Physician Payment
House and Senate: Immediately stabilize the Medicare physician payment system and hold hearings on long-term solutions to address the broken system.For more than twenty years, Medicare payments have been under pressure from the Centers.for Medicare and Medicaid Services (CMS) anti-inflationary payment policies. While physician services represent a very modest portion of the overall growth in healthcare costs, they are perennial targets for cuts when policymakers seek to tackle spending. Although surgeons and physicians in general were largely successful  in avoiding direct cuts to reimbursements caused by the Sustainable Growth Rate formula (SGR), which was enacted in 1997 and repealed in 2015, Medicare physician payments remain constrained  by a budget-neutral financing system.Updates to the Conversion  Factor (CF) have failed to keep up with inflation or fallen in real terms year after year. The result is that the CF today is only about 50% of what it would have been if it had simply  been indexed to general inflation starting in 1998.
Additionally, the Medicare Access and CHIP Reauthorization Act (MACRA) took steps to move away from a fee-for-service (FFS) system and to tie payment more closely to value. However, MACRA implementation has fallen short, leaving physicians stuck in a broken payment system without meaningful  opportunities to participate in value-based payment arrangements designed to improve quality and reduce costs to patients.
Congressional  ActionOver the last several years, the negative impact of the Medicare Physician Fee Schedule budget neutrality requirements has been compounded  by the lack of an inflationary  mechanism and other congressional  policies, such as sequestration. Each year, these policies result in drastic cuts for medically necessary surgical care. Last December, Congress passed the Protecting Medicare and American Farmers from Sequester Act which mitigated a large percentage of scheduled Medicare payment cuts, however the law begins to phase the cuts in throughout the year.
We are thankful Congress intervened  to reduce the impact of cuts the last two years. Unfortunately, there are no planned increases to the CF until at least 2026, and as the congressional  relief expires surgeons will again be facing significant cuts at a time where physician practices are struggling to keep up with the rising cost of delivering care. These planned cuts are due to extraneous factors unrelated  to the value of care and, in some cases, not even related to health care policy at all.
CONGRESSIONAL  ASKCongress must stop these cuts from going into effect and create stability in the physician  payment system.
In addition to taking immediate action to prevent pending cuts, Congress should hold hearings to examine the long-term stability of the Medicare physician  payment system and to consider how MACRA could be improved to ensure surgeons can participate meaningfully  in the transition to value-based care as the law intended.
Ensure CMS is Implementing MACRA as Intended

The Medicare Access and CHIP Reauthorization Act (MACRA) intended  to tie payment more closely to value but has fallen short in implementation, leaving many surgeons without a clear path to succeed in the new environment. More than 20 different payment programs for quality and value exist in Medicare today, without unifying incentives to improve care coordination for patients. Further, despite targets for participation  in alternative payment models (APMs), many surgeons remain stuck in a fee-for-service (FFS) system due to the lack of qualifying models relevant to the care they provide.
Congressional ActionRepresentatives Kim Schrier (D-WA) and Larry Bucshon, MD (R-IN) are leading a congressional  sign-on letter to the Centers for Medicare & Medicaid Services (CMS), urging use of its Innovation Center to test and advance APMs developed  by the physician community  and approved  by the Physician-Focused Payment Model Technical Advisory Committee (PTAC). Additionally, the letter requests that CMS use the authority provided  by MACRA to adopt quality metrics that provide more meaningful data to inform care decisions and improvement efforts.
The CMS Innovation Center should test PTAC approved APMs.The process created  by MACRA to develop physician focused payment models has not been fully implemented. In 2016, ACS was the first organization to propose an APM to PTAC. That APM was recommended for limited scale testing the following year. Like ACS, other physician organizations spent years designing, developing, and proposing models to improve quality and reduce cost. These models were vigorously  reviewed and refined  by the PTAC and many were recommended for testing. To date, the Innovation Center has not acted to test any of the recommended  models, leaving specialists with limited  models that lack relevance for the patients they care for and the conditions they treat. The Innovation Center must test PTAC approved models developed by the physician community. Without qualifying  APMs relevant to surgical care, surgeons will continue to remain in a FFS payment system that does not achieve the intended goals of MACRA.
CMS must use existing flexibility to adopt evidenced-based, patient-centered quality measures.Congress enacted MACRA to transition to a value-based  payment system. However, many surgeons are assessed on quality measures unrelated to surgical care. Available surgical  measures frequently fail to reflect the complex, team-based  nature of modern care delivery. MACRA section 101(c)(2)(D) allowed for flexibility in developing quality measures provided  they "have a focus that is evidence-based." Unfortunately, CMS has not meaningfully used this flexibility, so surgeons and specialists often lack measures that reflect the conditions and patients they treat. CMS must use its existing authority  to adopt evidence-based quality measures that focus on the patient, reflect the team-based nature of modern surgical care, and incorporate the complexity of specialty care. Examples include measures based on verification programs, registry  measures, or other innovative concepts.
CONGRESSIONAL ASKHouse: Sign the Schrier-Bucshon letter to CMS. To sign on, please contact Alicia Bissonnette with Rep. Schrier (alicia.bissonnette@mail.house.gov) or Dylan Moore with Rep. Bucshon (dylan.moore@mail.house.gov). Senate: Weigh-in with CMS.
April XX, 2022
Chiquita Brooks-LaSure AdministratorU.S. Centers for Medicare & Medicaid  Services 7500 Security BoulevardBaltimore, MD 21244
Dear Administrator Brooks-LaSure:
As Members of Congress dedicated to the goal of advancing value-driven health care, we are writing to urge the Centers for Medicare & Medicaid  Services (CMS) to utilize the existing statutory authority granted to the Agency under the Medicare Access and CHIP Reauthorization Act (MACRA) to facilitate the transition to value-based  care. Specifically, CMS should  use the flexibility  provided in the MACRA to ensure more meaningful  and current quality data is  utilized  by physicians in their care of patients. Additionally, CMS should also test and advance alternative payment models (APMs) developed  by the physician community and approved  by the Physician-Focused Payment Model Technical Advisory Committee (PTAC).

Test APMS Approved by PTACMany physicians are left without meaningful  options to participate in value-based payment arrangements through APMs, leaving them in a broken fee-for-service system. MACRA set up a process for physician organizations and other stakeholders to submit innovative APMs for consideration and review.  The PTAC was to evaluate each model and make recommendations to the Secretary for which should  be tested or implemented. However, the CMS Innovation Center has yet to test a single APM approved  by the PTAC. Unfortunately, this means that nophysicians will be able to participate in physician developed payment models prior to the expiration of the 5% lump sum payment incentive intended to help facilitate the transition to value-based  care. CMS should immediately  use its existing authority and the resources of the CMS Innovation Center to test APMs that were recommended  by PTAC as intended  under MACRA.

Adopt Evidence-Based Quality Measures for a Broader Set of PhysiciansMACRA represented the culmination of Congressional efforts to replace a broken payment system with one that would increase the quality of care while reducing health spending. As physicians and CMS continue to implement the changes set forth in MACRA, it is our understanding  that the law continues to depend on outdated quality measures that have not kept pace with the complex nature of modern care. The language within MACRA under section 101(c)(2)(D) allowed for flexibility  in adoption of measures through alternative processes if they have an evidence-based focus.  This was a key provision intended to encourage developing quality measures to ensure successful  implementation of the law by providing participating physicians of all specialties with actionable information for improvement.  More patient-centered quality measures could also provide patients with critical information on where they can access safe, equitable, high-quality care. However, this flexibility
has largely gone unused leaving few options for non-primary care physicians to utilize quality measures that
are patient-centered and aligned  with the conditions they treat. CMS should  use its existing authority of MACRA to adopt evidence-based quality measures, including registry measures, or measures vetted and reviewed by consensus bodies other than the National Quality Forum (NQF) throughout the Quality Payment Program including in the Merit-based Incentive Payment System (MIPS), MIPS Value Pathways (MVPs) and APMs.Physicians have a deep understanding of what is necessary to achieve quality and safety  in the modern clinical context. These efforts may not always fit into the template envisioned  by the typical measure vetting and adoption process and may differ from typical CMS payment models. MACRA Recognized  these facts and provided broad flexibility and processes to allow for innovation from the physician community.  We urge CMS to better utilize its statutory authority where possible to work with key stakeholders in order to advance the goals of achieving meaningful  value-based care and better outcomes for all patients.Sincerely,Larry Bucshon, M.D. Member of CongressKim Schrier, M.D. Member of Congress
Ease the Burden of Prior Authorization

House: Co-sponsor the bipartisan Improving Seniors' Timely Access to Care Act (H.R. 3173). If already a co-sponsor, please urge committees of jurisdiction to advance the legislation.Senate: Co-sponsor the lmprovin   Seniors' Timely Access to Care Act (S. 3018).
Surgical  patients are encountering  barriers to timely access to care due to onerous and  unnecessary  prior authorization  (PA) requests from Medicare Advantage (MA) plans. Utilization review tools such as PA can sometimes play a role in ensuring patients receive clinically appropriate  treatment while controlling costs. However, the American College of Surgeons (ACS) is concerned about the growing administrative burdens and the delays in medically  necessary care associated with excessive PA requirements.
Congressional  ActionIn order to improve transparency  and efficiency  of the PA process in the MA program, Representatives Suzan DelBene (D-WA), Mike Kelly (R-PA), Ami Bera, MD (D-CA), and Larry Bucshon, MD (R-IN) and Senators Roger Marshall, MD (R-KS), Kyrsten Sinema (D-AZ), John Thune (R-SD), and Sherrod Brown (D-OH) have championed  the Improving Seniors' Timely  Access to Care Act (H.R. 3173/S. 3018). The bill has broad bipartisan support with more than 270 co-sponsors in the House and nearly a quarter of the Senate.
The legislation is based on a consensus statement on PA reform adopted  by leading national organizations representing physicians, medical groups, hospitals, pharmacists, and health plans. It would facilitate electronic prior authorization, improve transparency, and increase Centers for Medicare & Medicaid Services oversight on how MA plans apply PA requirements. Specifically, the bill would:
•     Establish an electronic prior authorization (ePA) process and require MA plans to adopt ePA capabilities;•     Require the Secretary of Health and Human Services to establish a list of items and services eligible for real-time decisions under a MA ePA program;•     Standardize and streamline the PA process for routinely approved  items and services;•     Ensure PA requests are reviewed  by qualified medical personnel;•     Increase transparency  around MA PA requirements and their use; and•     Protect beneficiaries from disruptions in care due to PA requirements as they transition  between MA plans.
CONGRESSIONAL ASKHouse: Co-sponsor the bipartisan Improving Seniors' Timely  Access to Care Act (H.R. 3173). If already a co­ sponsor, please urge corn.mittees of jurisdiction to advance the legislation.Senate: Co-sponsor the Improving Seniors' Timely  Access to Care Act (S. 3018).
Maintain A Strong Surgical Workforce

11House and Senate: Co-sponsor H.R. 5149/S. 1593, the Ensuring Access to General Surgery Act.General surgery is an essential element of a community-based health system. A shortage of general surgeons is a critical component of the crisis in health care workforce because only surgeons are uniquely trained and qualified to provide certain necessary, lifesaving procedures. In areas without general surgeons or with an insufficient surgical  workforce, patients in need of care must travel to a place with surgical capabilities, leading to delays in care and potentially suboptimal outcomes. The availability of general surgical care to a rural health system facilitates an expanded spectrum of services for a local population's health care needs. This obviates the need for transfer, time away from employment, travel, and associated costs.
Unlike other key providers of the community-based health care system, general surgeons do not have a formal workforce shortage area designation. A congressionally mandated 2020 report, conducted  by the Health Resources and Services Administration (HRSA), examined surgical shortage areas and showed a maldistribution of the surgical workforce, with widespread  and critical shortages of general surgeons particularly  in rural areas. Additionally, data from the Association of American Medical Colleges (AAMC) continues to project shortages of surgical specialties over the next 15 years.
The American College of Surgeons (ACS) believes that current data highlight the urgent need to establish a surgical shortage designation.
Congressional  ActionAs part of a multi-pronged  legislative approach, ACS was successful in securing language in the FY19 Senate Labor-HHS appropriations report that required HRSA to study access to general surgeons  by underserved populations (referenced  above).
ACS strongly supports the Ensuring Access to General Surgery Act (H.R. 5149/S. 1593), introduced  by U.S. Representatives Ami Bera, MD (D-CA), Larry Bucshon, MD (R-IN), Scott Peters (D-CA), and Markwayne Mullin (R-OK) and Senators Brian Schatz (D-HI) and John Boozman (R-AR). This important legislation would direct the Secretary of the Department of Health and Human Services (HHS), through the HRSA, to study and define a general surgery  workforce shortage area and collect data on the adequacy  of access to surgical services. Additionally, the legislation  would grant the Secretary of HHS with the authority to designate general surgery shortage areas.
CONGRESSIONAL  ASKHouse and Senate: Co-sponsor  and support H.R. 5149/S. 1593, the Ensuring Access to General Surgery Act. Determining  where patients lack access to surgical services and designating a formal surgical shortage area will provide HHS with a valuable new tool for increasing access to the full spectrum of high-quality  health care services.
Ensure Funding for ACS Priorities in FY 2023
House and Senate: To ensure robust funding for important priorities, the American College of Surgeons (ACS) respectfully requests consideration of the following appropriations priorities for Fiscal Year (FY) 2023.
MISSION ZERO FundingThe MISSION  ZERO Act, enacted in 2019, created  the Military and Civilian Partnership for the Trauma Readiness Grant Program  within  the U.S. Department of Health and Human Services (HHS), to cover the administrative costs for civilian hospitals to embed  military trauma professionals in civilian trauma centers. These grants allow military  trauma care teams to gain exposure to treating critically injured patients in civilian trauma centers and therefore increase readiness of military care teams when deployed, further advancing trauma care and providing greater patient access. By facilitating the implementation of military-civilian trauma partnerships, this program preserves lessons learned from the battlefield, translates those lessons to civilian  care, and ensures that service members maintain their readiness to deploy in the future. ACS supports funding the program at its fully authorized  amount of $11.5 million.
•     Military and Civilian Partnership for the Trauma Readiness Grant Program: $11.5 million (currently  $2 million)

Firearm  Research FundingAccording to the Centers for Disease Control  and Prevention (CDC), there were more than 45,000 firearm­ related fatalities in 2020, a marked increase over previous years. ACS believes this number can be reduced through federally funded firearms research. As with other injury prevention related efforts, public health research can play a role in reducing the number of firearm-related injuries and deaths. Federally  funded research from the perspective of public health has contributed  to reductions  in motor vehicle crashes, smoking, and Sudden Infant Death Syndrome (SIDS). ACS believes that a similar approach can provide necessary data to inform efforts to reduce firearm-related injuries and deaths.•     Firearm Morbidity and Mortality  Prevention Research:o    Centers for Disease Control and Prevention  (CDC):o    National Institutes for Health (NIH)

Cancer Research FundingThe National Cancer Institute (NCI): The    CI is experiencing a demand for research funding that is far beyond  that of any other Institute or Center (IC) at NIH. Between  FY 2013 and FY 2019, the number of research grant applications to NCI rose by 50.6%, compared to just 5.6% at all other ICs. That is good news because it shows how much excitement  there is in cancer research. But at its current funding level, NCI cannot keep up with that demand. Only  about one out of every eight applications  receives funding.•     National Cancer Institute (NCI):                                                                 $7.66 billion (currently  $6.9 billion)

CDC Cancer _Research Programs: Research is important, but so is prevention. About half of the 600,000 cancer deaths m the U.S. each year could be prevented through the application of existing cancer control initiatives. Unfortunately, funding for CDC's cancer programs has barely changed in a dozen years. From FY 2010 to FY 2022, funding rose by less than $20 million -  just 5%-   over 12 years ($370.3M to $389.8M).That's about $100 million less than if these programs had simply kept up with inflation.•     CDC Cancer Programs:                                                                   $456 million (currently $385.8 million)
Repealing the Ban in Sec. 510 Prohibiting a Unique Patient Identifier {UPI)Serious patient safety concerns arise if a patient's health record is mismatched  or includes inaccurate or incomplete information, potentially resulting in missed allergies, medication  interactions, or duplicate tests ordered. Unfortunately, there is no accurate or consistent  way for surgeons to link patients to their health information across the continuum of care, due to long-standing federal statutory language. The language,  located in Section 510 of the Labor, Health and Human Services, Education and Related Agencies Appropriations (Labor-HHS) bill, has prohibited  HHS from spending any federal dollars to promulgate or adopt a Unique Patient Identifier (UPI), thereby hampering public-private sector collaborative efforts to advance a nationwide patient identification strategy that is cost-effective, scalable, secure, and prioritizes patient privacy. Removing the language in Section 510 will provide HHS with the ability to evaluate a range of patient identification solutions and enable the agency to work with the private sector to explore potential challenges.The U.S. House of Representatives and U.S. Senate removed  the ban from draft versions of the Labor-HHS  bill for the first time in FY22, but unfortunately, the change was not included in final legislation.
•     Remove the ban in Section 510 of the Labor-HHS Appropriations bill text that prohibits HHS from spending any federal dollars to promulgate or adopt a UPI.
CONGRESSIONAL  ASKHouse and Senate: Please include ACS funding priorities in your Appropriations requests:•     Military and Civilian Partnership for the Trauma Readiness Grant Program (MISSION ZERO):$11.5 million (currently $2 million)•     Firearm Morbidity and Mortality  Prevention Research:               $50 million (currently $25 million)o    Centers for Disease Control and Prevention (CDC):        $25 million (currently $12.5 million)o    National Institutes for Health (NIH):                                 $25 million (currently  $12.5 million)•     National Cancer Institute (NCI):                                                    $7.66 billion (currently  $6.9 billion)•     CDC Cancer Programs:                                                                   $456 million (currently  $385.8 million)•     Remove the ban in Section 510 of the Labor-HHS  Appropriations bill text that prohibits HHS from spending any federal dollars to promulgate or adopt a unique patient identifier (UPI).
2022 Leadership & Advocacy Summit Report

INDIANA CHAPTER OF THE AMERICAN COLLEGE OF SURGEONS
