OPINION

Changing political realities and vascular surgeryRobert W. Oblath, MD, FACS, Encino, Calif

Vascular surgery has become the ward of the federalgovernment. This is because 70% to 80% of our patients areinsured by Medicare and the balance are insured by anentity that uses the Medicare fee schedule as the basis forpayment. Unfortunately, this fact is not going to change,and therefore, we must understand the ever-changing po-litical climate and its influence on reimbursement to sur-vive.

Vascular surgeons have paid dearly in lost reimburse-ment for reasons well known to us all. The concept ofbudget neutrality within the fee schedule, coupled with theestablishment of resource-based relative value units, hasresulted in the total micromanagement of our specialty.With the exception of continued refinement of practiceexpense relative value units over the next 14 months, thefee schedule in vascular surgery is essentially fixed until thenext 5-year review for work and practice expense.

Why is politics at the federal level playing such animportant role? Simply, because the looming baby boomgeneration becomes Medicare eligible in 2011, with only afinite amount of money available to provide for its care. Thepopulation is expected to grow 30 million by 2010, and theeligible Medicare population to grow to 47 million from 39million currently over that same time period. By 2025,there will be 70 million Medicare recipients (20% of the USpopulation). Allocation of scarce dollars through the feeschedule becomes most important, and the ultimate con-trol of these funds becomes the conversion factor—thatmysterious number that converts relative value units todollars. Access to healthcare for the Medicare recipient isseverely threatened by the confluence of increasing num-bers of patients, decreasing reimbursement to physicians,and the increasing cost of technology and pharmaceuticals.The major driver of healthcare costs is technology, an evermore expensive influence on the cost of care.

Because we as vascular surgeons care for large numbersof Medicare recipients, it is important to understand these

factors. “Access to care” is the buzz word of the politician.Anything that interferes with access of the senior popula-tion to their physician will adversely effect the politician atthe voting booth. After all, the ultimate goal of the politi-cian is power, and to get power, votes are needed to stay inoffice. Restriction of care is a potential problem because ofthe interaction between reimbursement and patient num-bers.

The conversion factor is currently the product of theMedicare Economic Index (an index of inflation within thecomponents of the resource-based relative value system)and the Sustained Growth Rate (SGR). The SGR is acomplex number based on the rise or fall of the grossdomestic product (GDP), an increase or decrease in fundsmandated by Congress, and the number of fee-for-serviceMedicare patients and the physician costs of treating thoserecipients. It is these last two factors that are most impor-tant in establishing the conversion factor. These two com-ponents are based on an expenditure target established byCongress and the Center for Medicare and Medicaid Ser-vices. If the expenditure target of the current year, asmeasured against previous years, is exceeded, then theconversion factor drops and vice versa. These targets arearbitrary and based on uncorrected data from previousyears. Thus, there can be large swings in the SGR on ayearly basis. This mechanism is further complicated withuse of the GDP to determine physician salary. I do notbelieve salaries in any other sector of the economy aredetermined by the GDP.

The Medicare Payment Advisory Commission has rec-ommended elimination of the SGR in determination of theconversion factor and replacement with inflation indicesonly. The cost of this change is 130 billion dollars over thenext 8 to 9 years. This “charge” is to be taken againstphysician reimbursement. If the economy improves or thefederal government increases funding to physiciansthrough the conversion factor by law or mandate, then the130 billion dollars will be reduced and physician reimburse-ment will stabilize. This is unlikely, however, and it isestimated that there will be further decreases in the conver-sion factor and thus income approaching 20% over the nextseveral years. Why? Simply because both Democrats andRepublicans believe either that beneficiaries should getincreased benefits or that physicians can absorb the cost ofthe conversion factor cuts.

From the Government Relations Committee AAVS.Competition of interest: nil.Reprint requests: Robert W. Oblath, MD, FACS, University of Southern

California, 16500 Ventura Blvd, Ste 360, Encino, CA 91436 (e-mail:ahon@pacbell.net).

J Vasc Surg 2002;36:414-5.Copyright © 2002 by The Society for Vascular Surgery and The American

Association for Vascular Surgery.0741-5214/2002/$35.00 � 0 24/9/126313doi:10.1067/mva.2002.126313

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This is also an election year in which small segments ofsociety (little voting power) receive little attention. Largeblocks of voters, such as members of the American Associ-ation of Retired Persons, are coveted rather than a smallnumber of vascular surgeons who care for those members.The Jeffords’ bill of 2001 had huge filibuster and veto-proof support in both houses of Congress but never cameto the floor for a vote. The bill, as of this writing, has notemerged for a floor vote. Such is the interest in physicianwell being in April 2002.

What is the impact of these socioeconomic and politicalrealities? The most important is access to care for the seniorpopulation. Vascular surgeons will always take care of theMedicare patient simply because that is the age of ourpatient population and the disease process we treat. Thereal issue is whether there will be enough vascular surgeonsin the year 2011 and beyond. Older vascular surgeons are

retiring earlier along with their colleagues in other surgicalspecialties. Thus, the population is losing its most knowl-edgeable and most experienced surgeons at a younger age.The number of trainees in both general and vascular sur-gery is dropping. Boarded general and vascular surgeonsperform more than 65% of vascular procedures per year.The recent intern/resident match (2002) revealed a signif-icant number of unfilled positions not destined to be filledby foreign medical graduates. Why? My guess is a purelyeconomic one. Large college and medical school debt andlong years of residency and fellowship training (5 to 8 years)coupled with low surgical reimbursement are leading the“best and the brightest” away from surgical careers. If thistrend continues, access to vascular surgical care will not bean issue of seeing the specialist but rather of whether therewill be a specialist to see.

Submitted Apr 24, 2002; accepted Apr 24, 2002.

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