1

Surgery and government: A post-Surgery and government: A post-election update from Washingtonelection update from Washington

John Maa, MD FACSDepartment of SurgeryUniversity of California, San FranciscoDecember 16th, 2010

2

The impact of health reform in The impact of health reform in Washington DC upon surgery Washington DC upon surgery

The American College of Surgeons vision

The Palo Alto VA – “scope of practice” and “learning curve”

The anatomy of a malpractice lawsuit

The tools in health policy advocacy Next steps for surgery

3

A special place in Washington DCA special place in Washington DC

4

5

6

5 signers of the Declaration of 5 signers of the Declaration of Independence were physiciansIndependence were physicians

7

Dispelling myths – Paul Revere’s Dispelling myths – Paul Revere’s midnight ride and Dr. Samuel Prescottmidnight ride and Dr. Samuel Prescott

Paul Revere (MFA) Samuel Adams

8

What is the impact of ACA on surgery? What is the impact of ACA on surgery?

Expanding coverage through Medicaid may overwhelm an already struggling healthcare delivery system.

How will we care for 32 million more Americans?

Is this real reform?

1) Independent Payment Advisory Board 2) Patient Centered Outcomes Research Institute3) Center for Medicare Innovation4) Accountable care organizations5) Will the medical home raise costs?6) Increased support of rural surgeons7) Redistribution of general surgery residency positions

9

10

The ACS priorities – Executive Director The ACS priorities – Executive Director Dr. David HoytDr. David Hoyt October 2010October 2010

1) Payment reform & SGR fix2) Accountable care organizations3) Center for Medicare & Medicaid Innovation4) Bundling 5) P4P and NSQIP

“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.”

How will we ensure an adequate trained workforce to care for 32 million more Americans?

11

What are the next steps in DC? What are the next steps in DC?

January 3, 2011 – the 112th Congress convenes

Late January – State of the Union address

Feb 2011 - 1 year to the Iowa and New Hampshire caucus for the Presidential election of 2012

Later 2011 - A Supreme Court hearing on the “individual mandate”, which has now been deemed unconstitutional in Arizona, Oklahoma, and Virginia

12

May 2010 - the new ACS headquarters May 2010 - the new ACS headquarters – a forward base near Capitol Hill….– a forward base near Capitol Hill….

Thomas Circle

13

Glaucoma care at the Palo Alto VA – the Glaucoma care at the Palo Alto VA – the sentinel event in 2009sentinel event in 2009

A Veteran treated by the Optometry service since 2005 was seen for the first time by Ophthalmology and was found to have

progressive visual loss

14

Glaucoma – one of the blinding Glaucoma – one of the blinding diseases – damage to the optic nervediseases – damage to the optic nerve

Open chronic vs acute closed angle

“Silent thief of sight”

Medical Rx with prostaglandin analogs, beta agonists

Surgical Rx to lower IOP

15

Sacramento, California – the center of Sacramento, California – the center of a national scope of practice battlea national scope of practice battle

16

The learning curve in OptometryThe learning curve in Optometry

17

July 2009 – the role of the mediaJuly 2009 – the role of the media

18

A strong response of the California A strong response of the California Optometry AssociationOptometry Association

19

VA loophole in credentialing as a way VA loophole in credentialing as a way to expand optometry scope of practiceto expand optometry scope of practice

The VA allows providers to practice with certification from a different state.

The Chief of Optometry was licensed in Washington.

This confusing variation nationally regarding oversight, competency, and credentialing highlights overlapping state and federal concerns

20

A slow inquiry…..A slow inquiry…..

21

The origins of a lawsuit…The origins of a lawsuit…

After being informed by the VA, Mr. Woodward followed instructions to file a grievance.

He did not hear a response after 6 months, so he retained counsel to file a tort complaint.

22

Anatomy of a medical malpractice Anatomy of a medical malpractice lawsuitlawsuit

23

24

25

Do the federal government and VA have Do the federal government and VA have “sovereign immunity”?“sovereign immunity”?

Malpractice plaintiff attorney – “it is virtually impossible to win a case against the VA.”

Under the FTCA, the U.S. is subject to liability for the negligence of an independent contractor if it can be shown that the government had the authority to control the performance of the contractor, and exercised substantial supervision over daily activities.