Fellows identify key issues affecting surgery.

All changes in our health care delivery system during the past three years have had an effect on reimbursement rates, net income, and practice satisfaction among surgeons. Implementation of the Medicare fee schedule and increasing penetration of the health care market by managed care firms have clearly had the most profound influence. Sixty percent of practicing surgeons have experienced a decrease in net practice income since 1992. Of referrals from required gatekeeper physicians, 15 percent of such episodes are viewed by surgeons to result in decreased quality of care. Finally, there was a surprisingly high (40%) enthusiasm for implementation of a federalized single-payor health care system.