Editorials in three local newspapers are calling for a balanced approach to  cost control on the eve of the Senate’s debate over Bill 2070, its health care bill.

Excerpts:

Boston Globe: On Beacon Hill, Some Good Ideas, Some Overreach on Health Care
“The best course forward would be for the House to jettison its heavier-handed approach …  to focus on reinforcing the market-driven cost-cutting trends already underway.” (May 14)

Boston Herald: Healthier Approach
“Where the House leaders say their bill strikes the proper balance between government intervention and respect for market-based forces, the Senate bill seems to actually do so.” (May 14)

Boston Business Journal: Risking Jobs at the Expense of Payment Reform
“Here’s one way Beacon Hill could help contain costs. Liberate the market so insurers could offer a more dynamic mix of products. Massachusetts’ one-size-fits-all approach forces many consumers to buy far more than what they want or need.” (May 11)

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By Lynda M. Young, MD
MMS President

With the release of the Senate bill today, we now have two detailed legislative approaches to payment reform, along with the Governor’s legislation from last year.

We recognize the need to bend the cost curve in Massachusetts, and we will continue to work with the House, the Senate and the Governor for the remainder of the session to ensure that the final legislation aligns with the following principles.

We assert that the market is working, and has already been doing an effective job controlling the growth in the cost of health care over the last two years. The most responsible approach to continuing this trend would be to empower this market-led approach.

A market approach would afford us the best chance of ensuring that patients’ access to care is preserved; the delivery of quality health care is supported; that we continue to foster innovation; that we maintain the viability of physician practices, and protect the jobs of the many thousands of people who work in health care –without disruption or interruption.

We support an approach that establishes a reasonable cost control goal over a reasonable period of time. If these reasonable goals are not met, then a detailed review would be initiated, which would inform a set of targeted actions to fairly address the causes of the problem. Any benchmark below the annual growth in the state’s economy is too aggressive.

This is a very complex system. Massachusetts is already among the nation’s leaders in designing new models for the delivery of health care. State legislation should foster the innovations that are currently underway. It should allow us the opportunity to learn what works, and provide the flexibility to make corrections when needed. This is an imprecise science, and no one has done anything like this before. This must be a gradual learning process, conducted in a non-punitive environment.

We also need to be mindful of the risk that a new statutory framework could add administrative burdens on providers and payers who are already staggering under the weight of administrative mandates, many of which add no value to health care. We must simplify, not complicate the administration of health care.

We are pleased to see language modeled on the University of Michigan’s Disclosure, Apology and Offer approach to resolving patients’ claim of medical malpractice. This would lead to the faster resolution of cases, increase openness and honesty between patient and provider, allow for provider apologies, reduce the incidence of defensive medicine, and help control and reduce costs. We believe this model would vastly improve the experience of patients with an unanticipated medical outcome, and better foster a culture of safety in our health care system.

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The Massachusetts House Friday released a comprehensive payment reform bill that seeks the cut $160 billion in health care spending in Massachusetts over the next 15 years.

House Speaker Robert DeLeo characterized the bill as an effort to balance the need to cut health care costs for employers and families with a desire to keep health care “a healthy part of our economy.”

Rep. Stephen Walsh, co-chair of the Joint Committee on Health Care Financing, said health care stakeholders “may not like everything [in the legislation], but you certainly will like something.”

The bill spans 178 pages and more than 3700 lines of text. Its provisions include:

• There are firm targets to encourage health care providers to limit increases in health care costs. In Year 1, annual spending growth may not exceed the growth in the Gross State Product. In Year 3, that target is reduced to a half percentage point below the growth in the Gross State Product. If providers exceed these targets, the state is empowered to change payment methodologies, propose new legislation, require corrective action plans, or reopen providers’ contracts with insurers.
• Providers whose costs exceed 120 percent of the comparable state median would be fined at 110 percent of their spending that exceeds that 120 percent level.
• A comprehensive adoption of the so-called Michigan model of “disclosure, apology and offer” to resolve patients’ claim of medical malpractice. This includes the establishment of a 182-day waiting period upon the filing of a notice of a claim. It prohibits the introduction into evidence of a provider’s expression of apology or regret.
• A powerful new independent agency, the Division of Health Care Cost and Quality, would consolidate the role of many existing agencies and oversee the implementation of the bill.
• To improve transparency of prices and costs, there are new requirements on providers and insurers to publicly report costs and quality information, and patient cost-sharing.
• It provides for loan forgiveness for primary care providers practicing in underserved or rural areas.
• It seeks to simplify certain administrative procedures, and includes a requirement that all health plans must use the same two-page form for all prior authorization requests.
• It requires that all patients have access to an interoperable electronic health record by 2017. The bill promises an unspecified amount of financial support to help providers develop their EHR systems.

MMS President Lynda M. Young, MD, applauded the inclusion of the Disclosure, Apology and Offer language in the legislation. “We’re very supportive of the approach outlined in the legislation, which we believe will vastly improve the experience of patients who experience an unanticipated medical outcome,” she said.

Dr. Young expressed concerns about the legislation’s cost control mechanisms. “While we certainly appreciate the need to make health care more affordable, we’re worried that the bill’s goal and timetables are too aggressive. We look forward to working with the House and Senate to develop mechanisms that address patients’ affordability concerns, without reducing their access to care, unduly restricting physicians’ ability to practice medicine, or putting a damper on our state’s culture of medical innovation.”

Dr. Young added, “We appreciate Rep. Walsh’s openness and diligence during this long process. He met with us many times, and listened carefully to everything he had to say. We look forward to working with him, and members of the state Senate, during the coming weeks and months.”

The full text of legislation is available here. We’re continuing to analyze its details and will publish the product of that analysis next week.

According to Speaker DeLeo, the House bill will remain in the Ways and Means Committee for further analysis. The Senate, for its part, is expected to release its version of payment reform next week.

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It’s no secret to health professionals that Information technology is sweeping through the industry. The Federal government is deciding on “meaningful use” and allocating millions to establish systems. Providers are hurrying to install systems, establish competency and “get up to speed” for both federal and state requirements. And physician practices and hospitals are contending with “interoperability” – the ability of computers used by different hospitals or different practices to talk to each other.

But patients may not be so aware of these developments.

So, with the idea of raising patient knowledge about health IT, the May edition of Physician Focus, features two members of the MMS Committee on Information Technology.

Thomas Sullivan, M.D., (photo, right) cardiologist and MMS Past President, and Hugh Taylor, M.D., (center) a primary care physician in Ipswich, Mass., join host Bruce Karlin, M.D. (left) in discussing the basics of how health IT is changing the way physicians practice medicine and the way patients receive care.

Among the topics of conversation are the advantages and current limitations of health IT; how such tools as e-prescribing and electronic health records are enhancing care and reducing errors; the importance of – and distinctions among – the issues of privacy, confidentiality, and security; and how health IT holds the potential of making health care better, safer, and less expensive.

Physician Focus is available for viewing on public access television stations throughout Massachusetts. To view online, visit www.physicianfocus.org. Physician Focus is also available on iTunes at www.massmed.org/itunes.

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An alliance of major health organizations, led by the Massachusetts Medical Society, last week announced an effort to transform the medical liability system in Massachusetts by releasing a Roadmap to Reform that proposes an approach of Disclosure, Apology and Offer in settling medical liability cases.

The Roadmap is the result of a 2010 planning grant from the Agency for Healthcare Research and Quality, part of the President’s Patient Safety and Medical Liability Initiative, made to MMS and Beth Israel Deaconess Medical Center to explore alternative approaches to the current tort system of medical liability.

The alliance contains some of the most notable health groups in the state and includes major teaching hospitals, statewide provider groups, and patient safety organizations. Besides the Roadmap, the alliance announced that seven hospitals will begin pilot programs to test the impact of this new approach. The effort is being supported in part by three of the major health insurers in the state.

DA&O offers patients a full disclosure of what happened and why (and what will be done to prevent a recurrence of the event), and for events deemed avoidable, a sincere apology and appropriate and timely offer of compensation. It won’t deny patients the right to bring legal action, but would make tort claims a last resort.

The medical groups believe DA&O can increase transparency and trust, reduce lawsuits, cut down on defensive medicine, provide for faster and fairer resolution of cases, and improve patient safety.

Initial reactions by providers and policymakers have been positive, including those from editorial writers at some Massachusetts newspapers. Here are some excerpts, with links to the complete editorials:

Boston Herald “Of course it’s nice when health care providers acknowledge their mistakes. It’s even nicer to know that doing so could save money on malpractice claims that help drive up the cost of health care for all of us. Fewer claims may even lead to a reduction in the practice of so-called defensive medicine — fewer unnecessary tests, fewer unnecessary scans — and may bring down the cost of malpractice insurance, which has driven some practitioners from higher-risk fields.”

The Standard-Times of New Bedford In an editorial headlined ‘Sorry’ shouldn’t be the hardest word, “Physicians’ ethical duties are commonly, and understandably, trumped by fear and self-preservation when negligence or complications deliver unexpected outcomes for patients. Fear has created a system of outrageous payouts, malpractice insurance premiums and legal expenses…..Evidence is piling up that this approach is greatly preferable to “deny and defend,” the prevailing approach today.”

The Enterprise of Brockton “The court system must always be an option for those wronged by their health care providers, but a new effort to reduce doctors’ outsized fear of such cases has the potential to put a significant dent in out-of-control medical costs…..the program does have the potential to improve what all agree is a lengthy and expensive way of addressing medical mistakes.”

The MetroWest Daily News, Framingham and The Milford Daily News “The modern malpractice system turns considerate common sense on its head. Physicians are discouraged from apologizing to patients injured by avoidable error, lest the admission be used against them in a court of law…. The Massachusetts Medical Society and a group of seven hospitals are trying something new: an approach based on common sense and compassion.”

For more information on the program, read an executive summary here.

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When does the public’s health trump individual liberty? Are there unintended consequences to regulations aimed at promoting public health?  And what are the effects of public mandates in the day-to-day practice of medicine?

More than 100 physicians and public health experts attended the Massachusetts Medical Society’s eighth annual Public Health Leadership Forum on Wednesday to consider these and other questions.

The forum “Mandating Public Health,” presented by MMS with the Harvard School of Public Health, in concert with the Boston University School of Public Health, examined issues ranging from childhood vaccinations, nutrition standards on salt and trans fats, road safety regulations such as banning texting, and laws requiring seat belts and motorcycle helmets.

“We need to ask, Does it work?  How much does it cost? What rights have we taken away from someone else? This is a very important conversation to be having right now,” said forum moderator Harold Cox, a BU associate dean and gubernatorial appointee to the Massachusetts Public Health Council.

Brandeis professor Michael Willrich, the author of “Pox: An American History” offered a historical perspective
The issue of health mandates remains timely today. A national poll recently found Americans ambivalent about such laws aimed at healthy living; more than three-quarters agree that such initiatives do work, but nearly two-thirds worry that these laws restrict individual freedoms.on controversial compulsory vaccination programs. During the global smallpox pandemic at the start of the 20^th century, U.S. public health officials frequently carried out vaccination by force, provoking widespread public resistance and resentment, he said.

The Massachusetts legislature is currently considering more than three dozen potential new health care mandates – on top of the more than 40 that currently exist.

Wendy Parmet, associate dean at Northeastern University School of Law, and George Annas, chair of BU’s Department of Health Law, Bioethics and Human Rights, asked the crowd to consider whether public health mandates are ethical.

“There’s no question states have the authority to pass public health laws,” said Professor Annas. “The question is, should they?”

As technological advances increasingly make sophisticated genetic information easily and cheaply available to patients, physicians and government officials, great care will be needed in the crafting of future mandates concerning private health data, said Annas.

“We should look at health and human rights as a package. They are inexorably linked.”

The final speaker, James O’Connell M.D., president of Boston Health Care for the Homeless, described his two decades bringing health care to the homeless population of downtown Boston.

Typical public health mandates requiring TB tests, or forbidding cigarette smoking in shelters or hospitals, often meant his patients would refuse to seek treatment or leave care against medical advice.

Because of this, Dr. O’Connell said, his staff abandoned some of mandate in favor of provide better medical care for their specialized population.

“The question always is (with a disenfranchised population) what do you mandate? And what don’t you mandate?”

—   Erica Noonan

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Amid all the studies, research, and proposals swirling around health care reform, both locally and nationally, one constant seems to appear year after year: the high quality of primary care practiced by Massachusetts physicians.

That’s the main conclusion of the 2012 Massachusetts Health Quality Partners’ report, Quality Insights: Clinical Quality in Primary Care, released today. It is MHQP’s eighth annual study of primary care, summarizing care delivered throughout the Commonwealth by some 150 medical groups representing more than 4,000 primary care practitioners.

This year’s study shows that both adult and pediatric primary care providers continue to perform better than the national average across most of the two dozen services measured.

The report also found that pediatricians are among the best performing providers, with continued improvement year after year.  For example, on four of seven pediatric measures (testing for strep throat, treatment for upper respiratory infections, medication use for pediatric asthma, and well-child visits for the first 15 months of life), some medical groups reached the highest score of 100 percent.

Yet the report does issue a caution. While medical groups continue to provide high-quality care and improve, MHQP found that not all care is the same throughout the state or even within a single region in the state.  Among the key findings:  On every measure, medical groups have improved over the eight years of study; quality varies among medical groups across the state; most measures show wide variation among medical groups, emphasizing the need for continued improvement.

The report provides physicians information on which areas need improvement  and offers patients the opportunity to review the performances of local medical groups on a range of conditions, including care of diabetes, asthma, and cardiovascular disease, among others.  The full report is available at www.mhqp.org.

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To reduce the enormous burden of the nation’s number one cause of death, cardiovascular disease, the Centers for Disease Prevention and Control has launched the “Million Hearts” initiative, an effort to prevent one million heart attacks and strokes over the next five years.  The Massachusetts Department of Public Health (DPH) is leading the statewide public education campaign.

As part of the effort, the MMS and DPH have collaborated to produce the April edition of Physician Focus, Preventing Heart Attack and Stroke.

DPH Medical Director Lauren Smith, M.D., M.P.H. (right, photo), in conversation with program host and primary care physician Mavis Jaworksi, M.D., outlines the department’s efforts, describes the various risk factors for cardiovascular disease, and offers suggestions on the ways patients can prevent the disease and reduce the risks. Among the topics: high blood pressure; nutrition labels; the danger of too much salt in the diet; and the importance of exercise.

The CDC’s “Million Hearts” initiative stresses the ABCS of prevention – Aspirin therapy, Blood pressure control, Cholesterol management,  and Smoking cessation – and complements the efforts of the Massachusetts Department of Public Health to attack cardiovascular disease and reduce the number of heart attacks and strokes.

Physician Focus is distributed to public access television stations throughout Massachusetts. To view online, visit www.physicianfocus.org. Physician Focus is also available on iTunes at www.massmed.org/itunes.

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In an age where the federal government has settled on a total of 33 quality metrics in its final rule for accountable care organizations, figuring out how to track data and meet quality and performance benchmarks is becoming a critical part of a physician’s role in providing quality care to patients.

More practices in Massachusetts are focusing on data and analytics, because where risk-based contracts and accountable care delivery models are becoming increasingly prevalent. Understanding practice level and physician level data is a key to success, starting at the point of payer contract negotiation.

Many practices are challenged by where to start, which is not surprising given the alphabet soup that exists in terms of recognized metrics, HEDIS, NQF, NCQA, PQRI, PCPI to name only a few.

The good news is that while many are just beginning on this path, several practices have been operating in the data and analytics space for many years, and they are happy to share their lessons learned as well as the upside and downside of their experiences.

One such practice, South East Texas Medical Associates (SETMA), under the leadership of Dr. Larry Holly,  has worked to hone its data analytic capabilities to successfully manage their patient population, and has demonstrated success in improving metrics in areas such as diabetes management.

Of course, this is the result of years of evolution and a level of comfort with the metrics that are being tracked. That being said, SETMA has demonstrated success in working with the plans in risk based contracts as a result of their efforts.

Again, it took years for SETMA to perfect its strategy. One should not fear data tracking and analysis but embrace the initiative by starting with a few metrics that are important to the practice.  There is plenty of opportunity to tweak, improve and revise your processes over time.

As experienced practices such as SETMA will tell you, it’s about starting somewhere and perfecting your process over time.  On that note, why not start now?

If you’d like to learn more about how to approach data and how organizations like SETMA were able to successfully use data, join us at MMS on March 30th for the program titled “The Importance of Data in Physician Practice”.  Visit http://www.massmed.org/DataAnalytics2012

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By Lynda Young, MD
MMS President

In our medical society’s 230-year history, we have a long list of firsts. But we can take special pride that we were the first in the nation to promote the public release of the disciplinary records of all actively practicing physicians in our state. Our approach became the model for states across the nation.

The profiles were developed principally to help patients choose their physician. In fact, during the state’s own testing of the program in the 1990s, it was clear it would achieve its purpose. Patients said they were most pleased to see the information about physicians’ practice location, office hours, credentials, and the health plans they accepted. Disciplinary records were almost secondary.

A article in the Boston Globe and other newspapers on the state Board of Registration in Medicine and its physician profiles asks some pointed questions about that system.

It questions why the records do not cover care delivered outside of hospitals. The program was written to report on disciplinary actions in hospital settings, because in those venues, due-process protections are provided to both the physician and the person filing the complaint. To our knowledge, in nursing homes, health clinics and other organizations, there are no such due-process rights. Due process must be a basic building block of any public reporting system.

The article also highlights the case of a physician who had a jury return a large verdict against her and in favor of a baby born with cerebral palsy. The underlying care took place in 1996, the physician was licensed in Wisconsin in 1999, and the jury verdict came in 2005.  The article suggests that the Massachusetts profiling system somehow is deceiving the public by not in 2012 having information about this case listed in perpetuity.

We would suggest that every state bears the responsibility of doing its own homework on every prospective licensee, particularly since any state licensing agency can retrieve any malpractice verdict from the National Practitioner Databank. It’s not a difficult task, since every physician has a unique identifier that does not change, even if the physician changes his or her name.

The article also suggests that the medical profession is lax in holding its members accountable for failing to discipline those who fail to meet the standards of good medical care. However, the article uses entirely suspect information to reach that conclusion, by noting that physicians refer their colleagues to the medical board an average 41 times each year.

Leaving aside the wholly subjective judgment about whether 41 is a high number or low number, the number paints a substantially incomplete picture of what the profession does. The number does not count the physicians whose issues were addressed in peer review, rigorous highly-structured peer counseling, or otherwise. What other profession holds itself to account to such a degree?

The article also cites Public Citizen, whose reports equate the number of annual disciplinary actions by state medical boards with its competence. For many reasons, that methodology is even more suspect. As noted in the Mass. Medical Law Report, state to state comparisons are almost meaningless.

Certainly, transparency can address much of what ails the health care delivery system – as long as the information is accurate and is fair to all stakeholders. The Massachusetts physician profile program currently passes both tests.

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