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Become a member and receive career-enhancing benefits
Our top priority is providing value to members. Your Member Services team is here to ensure you maximize your ACS member benefits, participate in College activities, and engage with your ACS colleagues. It's all here.
ACS Advocacy Builds Momentum for Medicare Payment Reform
Don J. Selzer, MD, FACS, and Hallie Koch
September 2, 2026
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The ACS has been a leading voice in Medicare physician payment reform for decades and continues to lead these efforts on Capitol Hill and across the physician community. Ensuring appropriate surgical reimbursement is fundamental to maintaining access to high-quality surgical care for patients across the US.
The current physician payment system was established under the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, which was widely viewed as a meaningful and positive step toward value-based care and a transition away from the Sustainable Growth Rate (SGR).
Under the SGR, Congress was forced to enact repeated temporary legislative fixes to prevent automatic payment cuts whenever Medicare spending exceeded the economy’s target growth rate. Repealing the SGR and replacing it with MACRA was intended to shift Medicare toward value-based care while ending the cycle of annual payment reductions.
While the transition to the new system eliminated the annual financial cliffs associated with the SGR, it continues to impose annual payment cuts by reducing the Medicare Physician Fee Schedule (MPFS) conversion factor (CF), leaving physicians vulnerable to recurring reductions in reimbursement. Although many aspects of the current Medicare physician payment system function well, key components have created an unsustainable payment model that threatens surgeons’ ability to care for the nation’s most vulnerable populations.
An omnibus legislative package in 1989 (Public Law 101-239) created the current system used by the MPFS to value physician services, including the Resource-Based Relative Value Scale and Relative Value Units (RVUs). The legislation also established a budget neutrality requirement that has remained unchanged since 1992. As a result, when the value of some billing codes is increased, those increases must be offset by reductions in the value of other billing codes to maintain budget neutrality and control spending.
In addition, unlike other Medicare payment systems, the MPFS budget neutrality requirement is not coupled with a mechanism that adjusts physician payment for inflation. Together, these policies are significant features of the Medicare physician payment system and among the many external pressures that have contributed to the shift from independent practice to employed models. While decades of legislative and policy changes have shaped the current Medicare physician payment system, the value assigned to surgical care continues to erode. The ACS Division of Advocacy and Health Policy leads efforts to advance meaningful reimbursement reform, and surgeons play an important role in shaping the future of sustainable physician payment.
Current State of Medicare Physician Payment
Major surgical procedures with 90-day global periods continue to face reimbursement challenges, including payment instability caused by budget neutrality and the lack of an inflationary update, as well as calendar year 2026 MPFS changes, such as the efficiency adjustment and updates to indirect practice expenses. The ACS has consistently engaged with policymakers to address these long-term reforms, which are necessary to resolve structural issues in the MPFS.
However, urgent short-term issues often arise, and the ACS continues to be a leading voice on Capitol Hill, advocating for immediate relief. These issues typically stem from years of conversion factor cuts, the lack of adjustments to align Evaluation and Management (E/M) global codes with standalone E/M codes, and most recently, the efficiency adjustment. Although these challenges require prompt action, they also must be addressed while maintaining a robust strategy for long-term Medicare physician payment reform.
Both long- and short-term policy issues create financial strain and uncertainty for surgical practices, especially small and independent practices. Without an inflationary update, reimbursement fails to keep pace with the rising costs of operating a practice and employing staff, placing increasing financial pressure on physician practices. The budget neutrality requirement can further reduce reimbursement when certain codes are revalued upward, requiring offsetting reductions in the conversion factor. Because these annual cuts are unpredictable, practices face significant challenges in planning for the future when reimbursement levels remain uncertain.
The efficiency adjustment introduced additional unpredictability, under which all work RVUs were reduced by 2.5% without supporting evidence. This cut is the first of what could become a series of reductions under a recurring 3-year cycle in which work RVUs may continue to decline based on productivity data for the entire Medicare Economic Index (MEI), which is not physician specific. This cycle of RVU reductions affects all surgeons because RVUs determine direct reimbursement in private practice and serve as the basis for compensation in many employment contracts.
The current system of annual payment cuts, now compounded by an additional cyclical reduction, is unsustainable for surgery and threatens the future of the surgical workforce and patient access to high-quality surgical care. Although these policies impact employed and independent surgeons differently, the failure to adjust the conversion factor for inflation or the Consumer Price Index has placed increasing pressure on surgeons to increase hours in the office and OR.
Financial relationships and investments in healthcare facilities have helped surgeons, but surveys consistently show an average workweek of 60 hours or more, excluding time spent on call at home. Even before and during the early stages of the COVID-19 pandemic, unrealistic workloads contributed to high levels of burnout, prompting many surgeons to scale back their practices or leave clinical medicine altogether. Today, the average age of physicians leaving clinical medicine is younger than 50 years. Ongoing cuts to the conversion factor and the implementation of the efficiency adjustment have only exacerbated the problem.
Data published last year in the Journal of the American College of Surgeons demonstrate that surgical care has not become more efficient. In fact, it has become more challenging, requiring longer operative times. The implementation of the efficiency adjustment does not accurately reflect the current realities of surgical care. As surgical reimbursement has been steadily devalued over several decades, surgeons have compensated by working longer hours. As demand for surgical care continues to grow because of the nation’s aging population, balancing the needs of the patient with increasingly complex conditions has become more difficult. Without additional workforce capacity or more hours in the day, current payment policies threaten access to high-quality surgical care, particularly for patients with the most complex clinical needs.
ACS Advocacy: Leading the Charge
The ACS has a dedicated advocacy team in Washington, DC, that works with congressional and executive branch decision-makers on policies affecting surgical practice. Through direct lobbying and engagement of its grassroots network, the College has helped mitigate several years of planned MPFS CF cuts while continuing to advocate for broader physician payment reform.
The 2026 CF cut was prevented by legislation passed in summer 2025, due in part to the ACS’s consistent advocacy emphasizing the urgency of avoiding the reduction. The additional funding Congress provided to avert the cut was a clear sign that lawmakers value the physician workforce. However, temporary investments remain constrained by competing budget priorities and finite federal resources, making long-term physician payment reform more difficult to achieve.
Recent estimates suggest that implementing a permanent inflationary update would cost approximately $65 billion annually over the next 10 years. To put that figure in perspective, it represents about 4% of current annual mandatory federal spending. Despite its significant cost, the ACS continues to push for legislation that would provide a permanent inflationary update.
Improving payment stability and predictability is a central goal of the ACS’s advocacy efforts, and engaging key members of Congress is essential to building support for reforms with significant budgetary costs. One of the College’s most effective strategies has been coalition building. The ACS not only leads the surgical coalition on Capitol Hill but also works alongside the broader community of procedural specialties to restore work RVUs.
The ACS’s leadership on Medicare physician payment begins during the MPFS public comment period, when the College helps shape policy by responding to proposed changes and new initiatives.
As the impact of the proposed policies on affected specialties becomes clear, the ACS often identifies allies across the physician community. The College’s legislative team translates that information into a strategy to engage Congress while balancing political feasibility with opportunities for success. Once federal rulemaking in the executive branch is finalized, the most effective way to modify those policies is often through legislation. By engaging Congress, the ACS helps lawmakers understand how these policies affect surgeons and the patients they serve.
This approach is reflected in the ACS’s response to the 2026 efficiency adjustment. When the Centers for Medicare & Medicaid Services (CMS) first proposed the policy, the ACS submitted comments opposing the reduction as flawed and unsupported by evidence. In support of those comments, ACS Fellows and members of the Resident and Associate Society provided data refuting CMS’s assertion that operative times were decreasing. Using data from the ACS National Surgical Quality Improvement Program® (NSQIP), the authors published a peer-reviewed article during the public comment period. The publication was cited by the ACS and numerous healthcare organizations in their comments to CMS. Although CMS ultimately finalized the policy, the ACS shifted its focus to pursuing legislative action.
Using the evidence and data prepared during the public comment period, the ACS successfully advocated for the introduction of bipartisan legislation to address the cut: HR 7520, the Efficiency Adjustment Delay Act. The bill would prohibit future efficiency adjustments unless CMS provides evidence demonstrating the need for an across-the-board reduction in procedural RVUs.
While this bill is still in the early stages of gaining support, each step in the legislative process represents meaningful progress for the ACS’s advocacy efforts. Introducing bipartisan legislation is challenging in today’s political environment, and every additional cosponsor strengthens the bill’s prospects. As these incremental legislative successes translate into policy changes, ACS advocacy helps shape reimbursement trends, practice management decisions, and the long-term sustainability of surgical practices.
As surgical reimbursement has been steadily devalued over several decades, surgeons have compensated by working longer hours.
How Surgeons Can Get Involved
HR 7520 was a central focus of the 2026 ACS Leadership & Advocacy Summit (LAS), where surgeons from across the US traveled to Washington, DC, to meet with members of Congress and advocate for legislation affecting their patients, their practices, and the future of surgical care. Through the advocacy efforts of ACS Fellows, awareness of the bill has grown substantially, while the bill has gained bipartisan cosponsors.
By participating in LAS, surgeons have the opportunity to speak directly with members of Congress about the policy priorities the ACS advances year-round. The College extends those advocacy efforts through its Advocacy at Home program, which enables Fellows to meet with their congressional representatives in their home districts and continue those conversations throughout the year.
As the value of surgical care continues to decline, the ACS remains a leading advocate for surgeons, working with the broader physician community and providing Congress with trusted expertise on policies affecting surgeons and their patients. As a convener across the surgical community, the College helps shape sustainable solutions that benefit the full House of Surgery®.
The work of the ACS Division of Advocacy and Health Policy is strengthened by the collective voices of Fellows. Surgeons can participate through the SurgeonsVoice platform to communicate directly with their members of Congress and share how these policies affect everyday surgical practice and patient care.
Dr. Don Selzer, a general and bariatric surgeon, is the Willis D. Gatch Professor of Surgery, chief of the Division of General Surgery, and associate chair of the Department of Surgery at the Indiana University School of Medicine and Indiana University Health in Indianapolis. He also is an ACS Regent and Vice-Chair of the ACS General Surgery Coding and Reimbursement Committee.
Hallie Koch is a Congressional Lobbyist in the ACS Division of Advocacy and Health Policy in Washington, DC.
