The President’s Podium: A Step Forward in the Opioid Battle

Posted in Department of Public Health, Drug Abuse, opioids, Public Health on July 22nd, 2016 by MMS Communications – Be the first to comment

by James S. Gessner, M.D., President, Massachusetts Medical Society

Congress has helped Massachusetts and the nation take another step forward in the battle against prescription drug abuse. The Comprehensive Recovery and Addiction Act (CARA), a bipartisan effort incorporating several pieces of legislation targeted at opioid abuse, has been passed overwhelmingly by the House and Senate, and President Obama has signed it into law.

A compelling need to fund some of the law’s provisions still remains, but the symbolism and substance of its passage, like the enactment of Governor
Dr. James S. Gessner, MMS President '16-'17_editedCharlie Baker’s opioid bill in March, is hard to overstate.  According to the Centers for Disease Control, drug overdose deaths in the U.S. hit record numbers in 2014.  While heroin and fentanyl certainly claim their share of lives, prescription opioids continue to fuel the epidemic: at least half of all opioid overdose deaths involve a prescription opioid, and in 2014, more than 14,000 people died from overdoses involving prescription opioids. In Massachusetts alone, more than 1,500 opioid-related deaths occurred in 2015.

CARA includes several important provisions, including greater access to the life-saving therapies of naloxone and buprenorphine, help for infants and veterans, and the reauthorization of the National All Schedules Prescription Electronic Reporting Act, or NASPER, which provides for prescription monitoring programs that have proven to reduce opioid prescribing and overdose deaths.

One provision of CARA, however, can make a big difference: partial-fill prescriptions that will help patients balance the need to relieve pain with an adequate supply of medication by only filling part of a prescription.

The importance of a partial-fill prescription is that it can help to cut drug diversion – something that makes up a significant part of the opioid abuse crisis.  Estimates from the National Institute on Drug Abuse indicate that the majority of individuals – up to an astonishing 70 percent – who misuse or abuse pain medications get them from prescriptions written for someone else, such as family or friends.

Advocated by Massachusetts physicians, the partial-fill legislation was championed by Senator Elizabeth Warren and Congresswoman Kathrine Clark, who co-sponsored the Reducing Unused Medications Act of 2016 that became part of CARA. With few exceptions, U.S. Drug Enforcement Administration regulations had previously prevented partial-fill prescriptions.

While state law also now permits partial-fills, passed as part of the Governor’s opioid bill due to the efforts of Senator John Keenan of Quincy, the Federal law goes a step further by allowing the patient to fill the unused portion of the prescription, should patients need more relief.  State law currently does not.  This new provision in CARA will enable Massachusetts to change its law to become aligned with the new Federal law, as well as give other states the ability to pass partial-fill legislation.

In prescribing pain medicines, physicians are challenged with balancing the risk of addiction versus ensuring adequate pain relief for their patients. In efforts to reduce patients’ pain, however, too many prescriptions have been written, and prescription opioids have played a major role in driving this epidemic. Partial-fill prescriptions have the potential to shrink the amount of drugs susceptible to abuse and misuse or theft from unsecured locations such as family medicine cabinets – the place where Director of the White House Office of National Drug Policy Michael Botticelli has said the epidemic starts.

The law permitting partial-fill prescriptions is another in a long list of substantive efforts taken to address the opioid epidemic.  Here in Massachusetts, we perhaps have had more actions taken much sooner than elsewhere to fight opioid abuse. Governor Baker’s Opioid Working Group that led to bipartisan landmark legislation, law enforcement programs such as Gloucester’s Angel Program and the Middlesex County Sheriff’s Office MATADOR program for inmates, prescribing guidelines and prescriber education offered by our state medical society, and public information campaigns are among endeavors contributing to prevention, education, treatment, recovery.  These efforts, underway for more than a year now, are now beginning to see some results in recovery and reduced prescribing rates.

Another major step will be taken in August, when the Department of Public Health launches its new prescription monitoring program, offering enhanced searching capability along with access to data from other states.

These actions provide encouragement and hope. Yet despite this momentum, the rate of opioid-related deaths in the Commonwealth continues to climb  – a stark reminder of the human cost of this epidemic.  And those rising numbers keep sending us an important message: that’s there’s no room for complacency, a need for even more vigilance, and a long, long way to go before we can claim real progress.

The President’s Podium appears periodically on the MMS blog, offering Dr. Gessner’s commentary on a range of issues in health and medicine. 

 


July Physician Focus: Men’s Health

Posted in Physician Focus, Primary Care on July 1st, 2016 by MMS Communications – Be the first to comment

Studies and statistics confirm that when it comes to individual health, men fare far worse than women. Heart disease, substance abuse, injury and death from accidents all affect men far more than women.

Dr. Karlin (l) Dr. Schwartz (r) blog

“Men have really not taken good care of themselves,” says primary care physician Frederic Schwartz, M.D., co-chair of the Massachusetts Medical Society’s Men’s Health Committee. “There seems to be this ‘macho’ attitude where men feel that to access health care is not part of their creed. They delay care, they’re in denial, until it is too late.”

The differences between the sexes are large not only in visiting a physician, but also in listening to medical guidance, Dr. Schwartz says.  Women seem much more inclined in following through on the recommendations that physicians promote to maintain health.

Dr. Schwartz (photo, seated), an Assistant Professor of Medicine at the University of Massachusetts Medical School, offers his perspectives on men and health in the July episode of Physician Focus with program host Bruce Karlin, M.D., (standing) a primary care physician in Worcester.

The physicians discuss the reasons why men fall short on taking care of themselves and what they can and should do about improving their care.  Among other topics of conversation are prostate cancer, concern over the commonly prescribed Prostate Specific Antigen test; and how “low T” (low testosterone) and erectile dysfunction affect men’s health.

Physician Focus is distributed to public access television stations throughout Massachusetts, reaching residents in more than 275 cities and towns. It is also available online at www.physicianfocus.org, www.massmed.org/physicianfocus and on YouTube.

The President’s Podium: Encouraging Prescriber Education  

Posted in Drug Abuse, opioids, Public Health on June 24th, 2016 by MMS Communications – Comments Off on The President’s Podium: Encouraging Prescriber Education  

by James S.  Gessner, M.D., President, Massachusetts Medical Society

It is not an exaggeration to say that the Massachusetts Medical Society has been the leading health care organization in the Commonwealth responding to the opioid epidemic. For more than a year, we have been working with state and public health officials, legislators and other health care leaders and have developed multiple responses to address the crisis.  Gessner Crop

My predecessor, Dr. Dennis Dimitri, has been extraordinary in leading MMS over the past year and making the crisis the society’s number one priority. As Chairman of the Task Force on Opioid Therapy and Communication, I was privileged to be part of those efforts.

One of our major activities has centered on education, for both patients and physicians.  We have created a website and produced public service and video programs for patients, urging proper storage and disposal, consideration of alternative therapies, and discussions with their physicians on how best to treat pain.

One area we’re having significant impact is prescriber education.

This effort began with the issuance of our Opioid Therapy and Physician Communication Guidelines in May of 2015.  Developed with the most relevance for physicians and health professionals in primary care — those who prescribe the majority of pain medications – these guidelines were subsequently adopted by the Massachusetts Board of Registration in Medicine and incorporated into its comprehensive advisory to physicians on prescribing issues and practices.

In that same month, we started offering our continuing medical education courses on opioids and pain management free to all prescribers. We recognized early that prescriber education would be a critical step in addressing the opioid epidemic and that our society could make a significant contribution by sharing our resources.

The response to these courses has been encouraging indeed.

In a span of 13 months, from May 2015 through June 20 of this year, a total of 15, 175 of the Society’s continuing medical education courses in pain management and safe opioid prescribing have been completed by 5,265 individuals. Of those, 86 percent are physicians, and 66 percent practice in Massachusetts.

We currently offer 18 opioid and pain management online courses, with a range of content. Among the topics are managing pain without overusing opioids, managing risk when prescribing narcotics, safe prescribing for chronic pain, screening and evaluation of substance abuse disorder, and alternative therapies to opioids.  These courses are reviewed and updated regularly, to provide health professionals with the latest information on opioids and pain management.

Our prescriber education efforts, however, have gone even further, to include working with state public health officials and the deans of the state’s four medical schools in creating core competencies on opioids and pain management for medical school students and reaching out to academic medical centers in developing similar educational offerings for residency training programs.

Prescriber education remains one of the critical steps to alleviating the opioid crisis – a fact recognized by Governor Charlie Baker, who also realizes the key role physicians must play in resolving this crisis: “I think we have to be incredibly vigilant and aggressive about working with our colleagues in the health care world on this if we expect to have any long-term success at all,” he told The Boston Globe.

Physicians have a unique role in health care, and we are clearly demonstrating that with our response to the opioid epidemic. MMS will continue its efforts to educate physicians, to improve prescribing practices and reduce the amount of drugs that can be abused or misused.

The President’s Podium appears periodically on the MMS blog, offering Dr. Gessner’s commentary on a range of issues in health and medicine.

 

 

 

Men’s Health: Breaking the Resistance

Posted in Uncategorized on June 17th, 2016 by MMS Communications – Comments Off on Men’s Health: Breaking the Resistance

Resistance by men to medical care and treatments remains a vexing challenge as evidenced by the presentations of five clinicians at the Massachusetts Medical Society’s 14th Annual Symposium on Current Issues in Men’s Health on Thursday, June 16th.

The annual symposium is sponsored by the MMS Committee on Men’s Health, currently co-chaired by Frederic S. Schwartz, M.D. and Michael B. Bader, M.D., and seeks to promote awareness of men’s health issues and improve the overall health of men through education and information for physicians and other healthcare providers, researchers, and the public.  Some 60 health care professionals attended this year’s event, held during National Men’s Health Week.

Dr. Frederic Schwartz, Co-Chair, MMS Men's Health Committee

Dr. Frederic Schwartz, Co-Chair, MMS Men’s Health Committee

The opening presentations, on the treatment of Hepatitis C and alcohol dependence, were followed by a discussion on erectile dysfunction and its relationship to cardiovascular disease, and a presentation that reported how a cohort of male patients responded to questions about access to health care. The symposium concluded with a presentation about the health and identity issues transgender patients face when seeking medical care.

In his introductory remarks, MMS President James S. Gessner, M.D. underscored the urgency that surrounds these topics.

“Statistically, we face numerous challenges with regard to male patients,” Dr. Gessner said, “because men continue to be more likely than women to make unhealthy lifestyle choices. One in every five men will suffer a heart attack before they reach the age of 65. We must adopt a dual role as practitioners and catalysts, to treat men and to motivate them to live healthier lives.”

George Abraham, M.D., in his presentation titled Citius, Altius, Fortius: The New Standards of Hepatitis C, declared that “the saddest statistic we face is that while we have conquered HIV, the prevalence of cirrhosis is quite high, and men are increasingly the victims.” He said that liver transplants have increased and liver cancer is common among male patients. The good news, however, is that we are now headed to help cure this problem more rapidly than ever, thanks to medical and pharmaceutical advancements. Yet male patients must make a commitment to recovery and that practitioners must urge them to embark on this path, he said, or reinfection is possible.

Drawing on two American authors – Ernest Hemingway and F. Scott Fitzgerald — as examples of men who battled and later succumbed to alcoholism, Kenneth Hetzler, M.D., in his presentation, Alcohol Dependence and Best Practices for Treatment, explored alcoholism symptoms and treatments. Noting that both Hemingway and Fitzgerald paid a high price for their alcohol dependencies — depression, cirrhosis and, in Hemingway’s case, suicide — he urged physicians to engage in frank dialogues with their patients about their drinking habits so patients can grasp the risks of alcohol dependency and turn to resources for sobriety.

Martin Miner, M.D., cited another American author, Mark Twain, in his presentation, Erectile Dysfunction and Cardiovascular Function: What We Know.  Twain’s remark, “You can’t break a bad habit by throwing it out the window. You’ve got to walk it slowly down the stairs,” illustrated what Dr. Miner said is an effective approach to discussing and treating erectile dysfunction, a subject men find difficult to broach. Male patients must take small steps to change their lives, Dr. Miner said, which often include lifestyle changes. Noting that the relationship between erectile dysfunction and cardiovascular health is being clinically explored, Dr. Miner said that working with men to change slowly and understand the implications of their health challenges over time remains a key imperative.

James E. Leone, Ph.D., in his presentation Advancing Health Behaviors in Men: Understanding Men’s Perceptions Regarding Accessing Health Care, urged physicians to work with male patients to “unpack the behaviors” that lead to their resistance of healthcare. These include fear, control, time/convenience, trust, and other issues that emerged from his research as examples of resistance by men to seeking healthcare. “We need to create a more robust dialogue with men,” Dr. Leone said, “to bring men back to being active participants” in their own well-being.

Dr. Kevin Ard, the recipient of this year’s Men’s Health Award from the MMS, followed with a presentation entitled Transgender Identity and Health Issues, noting that LGBT patients have traditionally felt marginalized by the medical profession.  He encouraged practitioners to “make their clinical settings more welcoming,” and to use preferred names and pronouns, to ask patients about their identity and sexual orientation, and to remain open to them by avoiding assumptions about their health issues.

—Robert Israel

Editor’s Note: The slide presentations of  Dr. Abraham, Dr. Hetzler, Dr. Minor, Dr. Leone, and Dr. Ard are available here. 

 

 

 

 

 

 

 

 

 

 

The President’s Podium: Physicians and Gun Violence

Posted in Public Health on June 16th, 2016 by MMS Communications – 1 Comment

by James S. Gessner, M.D., President, Massachusetts Medical Society

Yet another mass shooting has stunned the nation, this time in Orlando, Gessner CropFlorida leaving 49 people dead and another 50 injured.  The home of Walt Disney World and the destination of thousands of tourists each year is now the site of the largest mass shooting in the history of America, joining such names as Columbine, Virginia Tech, and Sandy Hook, along with more than a hundred other places.

Such events are becoming all too common.  According to Everytown for Gun Safety, 133 mass shootings in 39 states occurred in the U.S. between January 2009 and July 2015 – almost two per month.  Yet as horrible and shocking as they are, mass shootings – defined by the FBI as any incident in which at least four people were murdered with a gun – account for a small share of firearm homicides.

The Centers for Disease Control estimates that more than 33,000 deaths from firearms – about 91 a day on average – occur each year.

The statistics make it abundantly clear: gun violence is a public health issue. And the physician’s voice – ever so critical on matters of public health – must become stronger.

The MMS stance on this issue has been firm and long-standing. Our medical society’s policy on firearms and gun violence is expansive and dates back to 1995. It is guided by “the principles of reducing the number of deaths, disabilities, and injuries attributable to guns; making gun ownership safer; promoting education relative to guns, ammunition, and violence prevention for physicians and other health professionals as well as for the public; and encouraging research to understand the risk factors related to gun violence and deaths.”

Our actions have matched our policy.  Our Committee on Violence Intervention and Prevention, also established in 1995, has provided a number of resources to help reduce violence in many forms, and gun violence has been prominent among the topics.

From testimony on proposed legislation on Beacon Hill, to education for patients, to resources for physicians on talking with patients, to our most recent Public Health Leadership Forum on Firearm Violence in April, to then-MMS President Dr. Richard Aghababian’s call to action following the school shootings in Newtown in 2012,  gun safety and gun violence have been key issues for our Society.

It is heartening to see more physician groups lend their strong support to the effort.  The American Medical Association, with longstanding policies on reducing violence from firearms, stated its position at this year’s annual meeting, adopting a policy calling gun violence in the U.S. “a public health crisis” that requires a comprehensive public health response and solution.  Perhaps most important, the AMA also resolved to lobby Congress to overturn legislation that for 20 years has banned the Centers for Disease Control and Prevention from conducting research on gun violence.

A second resolution by the AMA on firearm availability encourages legislation that would enforce a waiting period and background check for all firearm purchases and urges additional legislation to ban the manufacture, sale, or import of lethal and non-lethal guns of non-metallic materials that can not be identified by weapons detection devices.

In April of 2015, seven physician organizations, along with the American Public Health Association and American Bar Association, issued a call to action, declaring that “deaths and injuries related to firearms constitute a major public health problem in the United States.”

I am proud to say that more efforts at our medical society are underway. Our Leadership Forum will provide materials for six continuing medical education courses on gun violence to launch at the end of June.  Among the topics will be the role of the clinician, community-based prevention, and evaluating the risk for gun violence in patients.  Additionally, we are participating with Massachusetts Attorney General Healey in developing materials to enhance the provider-patient relationship regarding firearms.

The shock of Orlando may fade over time, but physician efforts to reduce gun violence should not.  Attorney General Healey, speaking at our Leadership Forum, highlighted the importance of physician participation in curbing gun violence, saying it will require a “partnership” with physicians.  Indeed it will.

The President’s Podium appears periodically on the MMS blog, offering Dr. Gessner’s commentary on a range of issues in health and medicine.

 

 

June Physician Focus: Infectious Disease: Fear vs. Evidence

Posted in Ebola, Flu, H1N1, Physician Focus, Public Health on June 10th, 2016 by MMS Communications – Comments Off on June Physician Focus: Infectious Disease: Fear vs. Evidence

The outbreak of an infectious disease is one of medicine’s most difficult challenges.  At the same time that public health agencies must contain the infection, they must also try to quell the public’s fears – a difficult task in today’s world of instant communication, multiple media channels, and constant media attention.  The experiences of Severe Acute Respiratory Syndrome in 2003, H1N1 Bird Flu in 2009, Ebola in 2014, Middle East Respiratory Syndrome in 2014, and now the Zika virus in 2016, are the most recent examples of threats targeting the public health.

June Physician Focus features Dr. Steven Hatch (r), with host Dr. Bruce Karlin

June Physician Focus features Dr. Steven Hatch (r), with host Dr. Bruce Karlin

The June edition of Physician Focus provides some perspective on the topic of media and public reaction to outbreaks of infectious disease through the experiences of Steven C. Hatch, M.D., an infectious disease specialist at UMass Memorial Medical Center and an Assistant Professor in the Division of Infectious Disease at UMass Medical School in Worcester. Hosting this edition is Bruce Karlin, M.D., a primary care physician in Worcester.

In 2014, Dr. Hatch spent five weeks in Liberia with the International Medical Corps treating patients stricken with Ebola and subsequently returned to that country several times to treat patients. Among the topics of conversation are what public health agencies must consider in reacting to infectious disease outbreaks, comments on how the media covered the Ebola outbreak in the U.S., and Dr. Hatch’s perspective on the latest outbreak of Zika.

Physician Focus is distributed to public access television stations throughout Massachusetts, reaching residents in more than 275 cities and towns. It is also available online at www.massmed.org/physicianfocus, www.physicianfocus.org/disease2016, and on YouTube.

 

Q&A with Dr. Catherine Brown of the Massachusetts DPH: What Physicians and Patients Should Know About Zika

Posted in Department of Public Health, Public Health on June 8th, 2016 by MMS Communications – Comments Off on Q&A with Dr. Catherine Brown of the Massachusetts DPH: What Physicians and Patients Should Know About Zika

Editor’s Note: Last week, the Massachusetts Department of Public Health posted new clinical guidance for physicians about the Zika virus on its website, which also includes handouts in multiple languages about the virus and travel advice for patients.

MMS spoke with Catherine Brown, D.V.M., M.S., M.P.H., Deputy State Epidemiologist and State Public Health Veterinarian at the Massachusetts Department of Public Health, about the potential for contracting Zika in the Commonwealth and what physicians and patients need to know.

We’ve seen a lot in the news about the Zika virus.
Should we be concerned about Zika virus in Massachusetts?
It’s extremely unlikely that we’ll see mosquito-borne Zika virus in Massachusetts.  The conditions in Massachusetts are not conducive to mosquito transmission of the virus here. In order for the Zika virus to spread, there needs to be widespread established populations of mosquitos and a significant number of people actively infected with that widespread population of mosquitoes.

Dr. Catherine Brown, Massachusetts Department of Public Health

Dr. Catherine Brown, Massachusetts Department of Public Health

The primary vector of Zika virus, not just in this current outbreak, and in almost all outbreaks, has been the yellow fever mosquito Aedes aegypti. This mosquito is more likely to spread disease because it breeds successfully in urban environments, and bites, almost exclusively, people–it doesn’t feed on other mammals—and unlike other types of mosquito, it takes multiple blood meals. Most mosquitoes take a single blood meal, so are less likely to transmit disease. The Aedes aegypti mosquito has not been found in Massachusetts.

The secondary vector is the Asian tiger mosquito Aedes albopictus. This is a non-native introduced species that is well established in the southern tier of the U.S. It feeds on humans as well as other mammals. There is some evidence, from Massachusetts mosquito surveillance, that we have geographically isolated and sporadic findings of Aedes albopictus. However, as with Aedes aegypti, there would need to be widespread established populations as well as significant numbers of actively infected people in contact with that widespread population of mosquitoes in order to spread the virus.  The people in Massachusetts who have been infected with the virus are travelers returning from affected areas; they don’t carry the virus in their blood for very long.

So the risk for people in Massachusetts relates to those traveling to or from an affected region.  What regions in and out of the U.S. are affected?
As of [this interview], there have been no cases of locally acquired, mosquito-borne transmission anywhere in the United States.  The areas involved in the current epidemic of Zika virus are most of Central and South America and the Caribbean, as well as Cape Verde and Papua New Guinea. The U.S. Territory of Puerto Rico has been particularly hard hit. This is the largest outbreak of Zika virus ever documented, both in terms of number of people infected and the geographic range of the outbreak. Because infection with Zika virus likely confers long-term immunity, previous outbreaks have waned relatively quickly as the percentage of susceptible people in the population declines.

Travelers concerned about the status of the Zika virus should check the CDC website for the most updated information on currently affected areas.

What are the symptoms of Zika?
Eighty percent of people infected with Zika virus will never develop symptoms. For those that do become symptomatic, the most common complaints are fever, a rash, joint pain and non-purulent conjunctivitis. Headache and pain behind the eyes have also been reported. For the vast majority of people, the illness lasts between two to seven days and is self-limiting. No specific treatment exists. Hospitalizations associated with Zika virus infection are rare but have been associated with Guillain-Barré, meningoencephalitis, and other neurologic problems.

It is not known if there are particular groups of people that are more likely to develop disease, or who are more likely to develop severe disease, including Guillain-Barré.  No evidence exists that pregnant women, infants, or children are at greater risk for developing disease and information about risk in immune-compromised patients is limited.

What is the risk from Zika to humans?
The most significant concern from Zika virus infection is for pregnant women who can transmit the virus to a developing fetus.

Right now, there are still more questions than answers about Zika virus.  We do know that women infected with Zika virus during pregnancy are more likely to give birth to an infant with birth defects or some other poor birth outcome. Exactly how much risk is associated with infection is not known. There is some information that infection with Zika virus during the first trimester, as opposed to later trimesters, is more likely to cause microcephaly in the developing fetus, but poor birth outcomes and other types of birth defects have been reported associated with infection during all trimesters of gestation. Microcephaly has received much of the attention; fetal loss, intracranial calcifications, and hearing and vision defects have also been reported.  It is not known how often vertical transmission –a mother with the virus transmitting it to a fetus—occurs, or how often this results in problems with the developing fetus or the pregnancy.

How should physicians counsel their patients?
Physicians should counsel pregnant women or those who want to become pregnant in the next two months that they really should not travel to areas where there is a reported threat of Zika virus transmission. If they do travel to those areas, they should wait eight weeks after returning before attempting conception.

Sexual transmission from symptomatic males has been documented, so male patients who have been symptomatic for Zika should use condoms consistently and correctly for all sexual contact for six months as a precaution to avoid transmitting the virus to a woman who may be, or may wish to become, pregnant.

What if the male traveled to an affected region, but has not been symptomatic for Zika?
Males who have traveled to an affected region but did not develop characteristic Zika signs and symptoms should use condoms consistently and correctly for all sexual contact for eight weeks after their last possible exposure.

If a patient has traveled to an affected area, what does the physician need to know?
Anyone who was pregnant when they traveled, or who became pregnant within eight weeks of returning, should be tested for Zika virus infection whether or not they developed symptoms of Zika.  If the male partner of a pregnant woman traveled to an affected area, testing of the pregnant woman (and sometimes her male partner), is indicated if either one of them develops symptoms of Zika virus infection.

Patients who develop Guillain-Barré syndrome following a Zika-like infection should also be evaluated for testing.

Why shouldn’t everyone who has traveled be tested?
Testing is not as simple as marking a checkbox on a lab test order. There are two types of testing: antigen-based and antibody-based. Whether the patient is symptomatic or asymptomatic, and the timing of specimen collection, determine what type of testing needs to happen. Right now, the commercially available, antigen-based test is only good for three to four days after the onset of symptoms, so this test is completely inappropriate for patients who have no symptoms. The Massachusetts State Public Health Laboratory has the ability to run both the antigen- and antibody-based tests; preliminary positive results from the antibody test require confirmation which is currently being done by CDC. Clinicians should check the Mass. Department of Public Health clinical advisory (found under the section, “Information for Health Care Providers” on the MDPH’s Zika website) to ensure they’re ordering the appropriate test for the patient.

Physicians should also keep in mind that it’s possible that pregnant women returning from the affected regions to Massachusetts to deliver their babies here have received virtually no prenatal care, and probably haven’t been tested previously for Zika. The pediatrician may be the first health care provider to recognize that Zika is involved. Physicians should call the MDPH Epidemiology Line at 617-983-6800 to determine if testing is recommended.  When Zika virus testing is appropriate, the results can help to inform the provider’s clinical decision-making and help to provide answers to parents.

Is the Department of Public Health tracking these cases?
Yes. While no single state is going to have enough data to draw all conclusions that we need to draw in order to guide clinical and prevention practices, individual states are collecting de-identified data from OB/GYN providers on pregnant moms with lab verified exposure to Zika virus. Additionally, states are working with pediatricians to follow the infants for 12 months after birth as part of participation in the U.S. Zika Pregnancy Registry being operated by CDC. Most information on the pregnant women can be collected during routine phone calls with OB/GYN providers to discuss laboratory testing and to share results. The Massachusetts Center for Birth Defects Research and Prevention within MDPH is aiding this effort by providing information on both the mother and the initial neonatal assessment as part of their routine work identifying infants with birth defects.  MDPH will work with individual pediatricians to gather the requested data in as unobtrusive a manner as possible. We have been delighted by the positive relationships being developed with providers who understand the importance of collecting this information. By collecting information on the progress of pregnancies and serial assessments of infants’ health, we hope to rapidly and completely identify both the risks of infection during pregnancies and the spectrum of possible effects to infants that might include more subtle developmental problems.

 

CMS’s Andrew Slavitt talks with MMS about MACRA

Posted in Electronic Medical Records, Health Policy, Health Reform, Payment Reform, Regulation on May 26th, 2016 by MMS Communications – Comments Off on CMS’s Andrew Slavitt talks with MMS about MACRA

Editor’s Note: On April 27, 2016, the Department of Health and Human Services issued a Notice of Proposed Rulemaking to implement key provisions of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), bipartisan legislation that replaced the flawed Sustainable Growth Rate formula with a new approach to paying clinicians for the value and quality of care they provide.  In early May, the Massachusetts Medical Society sat down with Andrew Slavitt, Acting Administrator of the Centers for Medicare and Medicaid Services, to talk about the new rule and how it was developed.  More information on the Proposed Rule can be found here.

MMS:  Recently you said that you thought CMS had lost the hearts and minds of America’s doctors, and the new MACRA rule was an opportunity to win them back. Can you tell us how you got to that point and why you think the new proposed rule will change physicians’ perceptions?

CMS Acting Administrator Andrew Slavitt

CMS Acting Administrator Andrew Slavitt

MR. SLAVITT: I want to start with mentioning that the Quality Payment Program that we put out in a proposal comes at a very exciting time in the evolution of Medicare. The implementation of MACRA allows us to take the next transformative step in the Medicare program, by introducing the Quality Payment Program to pay physicians and other clinicians for quality, with a more flexible approach, common-sense approach.  MACRA repealed the SGR and streamlined the patchwork of Medicare programs that currently measure value and quality into a single framework where every physician and clinician has the opportunity to be paid more for providing better care for their patients.  MACRA builds on the important reforms of the Affordable Care Act, which increased the numbers of Medicare clinicians participating in alternative payment models, which are models that reward coordinated, innovative care.

But, there is a lot of fatigue that has come with all the changes over the years. We know it can feel like there are people that sit around thinking of ideas for how to make a physician’s job more difficult; when what is really happening is the accumulation of requirements over time, passed in a series of laws or that come through a series of regulations. If people don’t implement and manage them carefully, we end up in a situation where I think we are now –  where despite all of the best intentions, the burdens add up for those on the front lines where care is given or received.

If people don’t feel like they’re being heard, if they don’t feel like they have a voice, and if they don’t feel like the changes make sense for their practice, it can be incredibly demotivating.

We have approached the implementation of MACRA with the belief that physicians know best how to provide high quality care to our beneficiaries.  And we have taken an unprecedented effort to draft a proposal that is based directly on input from those on the front line of care delivery.  Before drafting the Quality Payment Program proposal, we reached out and listened to over 6,000 stakeholders, including state medical societies, physician groups, and patient groups to understand how the changes we are proposing may positively impact care and how to avoid unintended consequences.

The feedback we received shaped our proposed rule in important ways—and the dialogue is continuing. Based on what we learned, our approach to implementation is being guided by four principles, which I think are also consistent with the goals of the MACRA legislation.

  • One is to keep the patient at the center, always.
  • Two, give physicians more flexibility to control their own destiny and to control what gets measured, how it gets measured and have a little bit more say in how things work, because I think that flexibility is a critical ingredient to some of the issues that we talked about.
  • Three, is simply to do less. Find opportunities wherever we can to reduce the burden. It’s as simple as that.
  • Fourth is simplify, simplify, simplify. That is something we try to take an opportunity to do in every place we could, whether it’s in the use of technology, whether it’s in taking this patchwork of programs and consolidating them and, it will be in how we ultimately implement many of the other components. We have an opportunity to really make a big change. What we’re going to have to do well is continue to listen, provide as much flexibility as possible and simplify.

At the end of the day, after thoughtful and skillful execution, it will be time that tells us how well we have done.

MMS:  You also talk about user-driven policy design. Can you talk about what that means and how it influenced the new Meaningful Use rules now called Advancing Care Information?

MR. SLAVITT: Sure. It’s actually not that radical a concept in the real world. In the real world it might be called “talking to your customers about what they want.” Perhaps in Washington, though, it is a bit of a new concept.

A great example of user-driven policy design would be the visit that you led us on when we were in Massachusetts: Sitting down and listening to what people who deliver care say about the impact of our work at CMS. There is no magic to it: just listen; translate needs into actions; create and deliver; communicate and seek further input; continue to iterate.

In a nutshell the big trap when doing public policy is to do it from your desk. The opportunity we all have – and it’s quite exciting for the people in the agencies – is to really get out there and think about what it feels like at the kitchen table of the American family, what it feels like in the clinics where people get care and how to improve on that. It is a wholesale different way of approaching this work.

When we implemented ICD-10, we used a bit of this approach, I think successfully. We are attempting to roll it out more significantly with the Quality Payment Program. I think you’re exactly right, the Advancing Care Information proponent of MIPS is a critical aspect which we took in a significant amount of input on.

And like I said, continuing to listen and iterate is a very important aspect of user-driven policy design. We are in the phase now of listening to input. And even after we publish the final rule, we will listen and iterate.

MMS:  You’ve also compared the new MACRA proposal to the rollout of an iPhone. So if you’ll forgive me for expanding on that analogy, even in Massachusetts there are physicians who are still using flip phones. You’ve also said, and I’m paraphrasing, that it’s okay to have payment models that aren’t perfect as long as we learn from them. How do you see these perspectives fitting into the implementation of MACRA, e.g., opportunities for physicians who are not used to taking on risk, learning how to bear more risk without fearing that they’re going to lose their practices?

MR. SLAVITT: It’s really important to put in context what payment model and incentives are supposed to do. I have never met a physician, nor do I hope to meet a physician, who makes decisions on patient care based upon how they’re going to get paid. I don’t think that’s how physicians are wired.

The role of payment models and incentives is simply to reinforce what the clinician believes to be the right way to deliver care. If incentives are done well and done right, clinicians will get reinforcement financially; and the payment system gives them the opportunity and the dollars to invest and reinvest in the kinds of things that they believe are right for their practice and for their patients. We have to make sure it is clear that we know it is the clinical and cultural leadership that improves quality, not public policy.

The point I was making about the iPhone is that we are in early generations of some of these payment models. The clinicians who participate should be aware that models are meant to reinforce the good practice of medicine, but the models are not going to be perfect. The models are going to have to get better over time based upon how they get used in the real world and improved upon. For instance, in our second generation models we have made changes, like adding telemedicine or adding patient incentives to make sure that the patient is aligned with their physician in staying healthy.

And where did the changes come from?  They came from listening to physicians and patients. The physicians tell us this model would be better if it could do this, if it could do that. And that’s the thinking that has to continue. So, like any other good, user-driven program, we want an ongoing dialogue so that year over year the program improves for patients and clinicians.

MMS:  So on to interoperability, which I know is one of your concerns. You know it’s one of the physicians’ greatest frustrations. Secretary Burwell has said 90 percent of EMR vendors are committed to interoperability, which is great. I think I can hear physicians nationally groaning because they think they’ve heard this before. So what is it that CMS can do and HHS can do to make it real?

MR. SLAVITT: Let’s talk about what interoperability really is. This is such an important ingredient to improving health care. But interoperability in some respects needs to just be as simple as this: how can we collaborate for the best outcomes when a patient is going to experience different parts of our fragmented health care system? What we want out of interoperability is simple: having a patient referred for other care and understanding what happens at that visit; or communicating with the physician when a patient is discharged from the hospital to make sure they are taken care of and are healing at home.

As you mentioned, Secretary Burwell announced that companies representing 90 percent of EHRs are committing to three vital steps to real interoperability. I thank the many who have made this commitment. It has the potential to set us on a new course, but we all need to be more committed than ever to making sure that the substance of this pledge translates to reality.

And you’re exactly right about physicians groaning; we are not talking sending a man to the moon. We are actually expecting technology to do the things that it already does for us every day. So there must be other reasons why technology and information aren’t flowing in ways that match patient care.

Partly, I believe some of the reasons are actually due to bad business practices. But, I think some of the technology will improve through the better use of standards and compliance. And I think we’ll make significant progress through the implementation of API’s in the next version of EHR’s which will spur innovation by allowing for plug and play capability. But the reason that the pledge is important is because the private sector has to essentially change or evolve their business practices so that they don’t subvert this intent.

In some respects, you can look at me and you can look at the government and say, “Why don’t you just mandate that people do this?”  We have very few higher priorities, but the reality is that if we really want change, we need everybody to put pressure on people in the system to make the technology work. So, if you are a customer of a piece of technology that doesn’t do what you want, it’s time to raise your voice. We’re doing everything we can to make sure that the technology vendors stop focusing on meeting the regulations, so they can start focusing on their customers and their users, and design around the physicians’ needs, the caretakers’ needs, the patients’ needs.

MMS:  We reached out to other medical societies nationally to get some questions for this interview, and they’re all interested in MACRA’s Quality Payment Program, including MIPS and APMs. Many of the questions had a pretty common theme: Physicians are willing to be held accountable for what they’re doing and they know they’re going to be graded on it, so to speak, but they’re concerned about being held accountable for things that are not under their control, whether it’s care that’s not under their control or let’s say a non-compliant patient for whatever reason. The other part of it was registries; how can the medical community be more involved and engaged with CMS in the development of these registries. So your thoughts on those two issues?

MR. SLAVITT: They’re very good questions. First, I’ll just go back to my earlier comment, which is that these payment models are intended to be strong signals about the kind of activities that improve patient care. And so, yes, a physician will feel like there are some things that they’ve got to really influence and pieces of the puzzle that they don’t control; we are interested in hearing about those and making sure that those make sense.

However, patient compliance is a tough but critical part of the process, and efforts to communicate to patients and so forth are obviously part of what physicians do and have been doing for a number of years. At the same time, we’re hearing amazing stories from physicians in small practices and rural, underserved communities.  Motivated and driven with a passion for patient care, they are redesigning their care teams around their patient needs in ways that are having dramatic impacts in patient compliance and health outcomes.  Meaningful impacts, such as significantly improving A1C levels – even as practices expanded to take on sicker, under-insured patients – and significant increases on follow through for referrals on behavioral health and addition referrals.  These are improvements that matter in our communities and in our homes.  And we’re hearing physicians say, “This is incredible! We’re practicing medicine again!”

We work very hard to create what we call a core set of measures, which means that we want to be on the same page with every other payer that’s in a physician’s office so that a physician can focus on one way of doing things.

For specialists, we’ve done a lot of work and a lot of collaboration.  Eighty percent of our measure sets are specialty specific, and the vast majority of those measures come from physician leadership outside of CMS where people are saying this is the evidence-based state of practice, this is what we want. We spent a lot of time engaging the clinical community – medical societies and front-line physicians – to design a program that’s equally meaningful to a wide range of specialties that practice in very different settings.  There’s plenty of ways to be successful within the Quality Payment Program. In addition, for small practices, we’ve designed our proposed rule to provide support and flexibility that match their circumstances, including increased technical assistance, exemptions for small volume practices, allowances for medical home models, and a continued focus on reducing reporting burden.  Our teams are set up to evolve these rules and the clinical community needs to continue to be a strong partner in this process.

MMS:  You are in charge of the most powerful agency in the nation to effect changes in health care in this country at the time of greatest change in health care. So what do you see as your role in this position and the role of CMS in helping shape the future of health care?

MR. SLAVITT: I think it’s really to listen to and absorb the voice of the people that are doing great care every day. We have 140 million consumers that are a part of Medicare, Medicaid and the Children’s Health Insurance Program, and the Marketplace.

If you start with that, let’s talk about what their life is like. They’re increasingly mobile. They’re connecting to an often fragmented system where they’re not anchored. Many of these 140 million, the vast majority are on modest incomes or fixed incomes. They may have family-care needs, both with parents and with children. They worry about how they’re going to pay for the next prescription drug or about missing their bus to their next dialysis appointment. They worry about whether health care is going to become too expensive to manage.

So if you keep it at that fundamental level, it makes, I think, our job pretty clear: represent the needs of the people we serve and to make sure those needs are getting met. CMS will continue to shape health care by making sure these programs are preserved, as well as evolve to meet the needs of the patients.

The wrong way to do that is to put a bunch of policy ideas together in a black box and try to implement them.

The best way – and it is very exciting – is to manage these programs by capturing both the voice of the patients and of the voice of the clinicians, represent those the best we can, and drive towards the delivery of high quality care.

MMS:  Is there anything else you want to say?

MR. SLAVITT: I want to thank you all at the Mass. Medical Society for the visit we had in Boston in the physician’s office. It is so important that we figure out how to connect public policy to what happens on the ground and in the real world. It’s invaluable. And we have to keep it up. It’s not one-off. It must be a cultural commitment. In fact, in the month of May alone, we have 35 scheduled events to hear from a wide range of stakeholders and this outreach will remain an important ongoing part of our work. I personally have been meeting regularly with physician groups, including smaller and rural practices, and have spoken to thousands of physicians in different parts of the country about their work, the opportunities and challenges they face, and what this proposal means for them and their patients.

The second thing I’d say is for physicians who are looking at these new regulations, to please get engaged. There is no possible way, for all the thinking our team can do, that we can anticipate every consequence of what we are working on. And as we aim to provide you with meaningful flexibilities, reduce your burden, and simplify how things get done, please help us think about how these programs can fairly and objectively reward you for the quality of care you delivery.

With all of the work that went into the proposal, it is critical that we receive direct feedback from physicians and other stakeholders. We rely heavily on the feedback for people to say, “I see your intent but what is happening is there’s an unintended consequence or there is a better way to lead us.” If physicians don’t get engaged, then consequentially they will feel the impact of things that they really could have influenced, and we want them to see that we are listening.

I know Washington can feel so distant, policy-making can feel so distant, and I think people are just, sheer exhausted for good reason, so sending in feedback can feel too difficult or pointless. But if this is truly able to be moved forward with all the input of the people who take care of all the beneficiaries (who I like to think actually run Medicare every day), then these new improvements will go so much better, and the Medicare program, the patients in these programs, and the practice of medicine will be the better for it.

I recognize that it’s not the talk, but how we act together, that moves things forward. Which is why I think the change from Meaningful Use to this new, much simpler, much more flexible program of Advancing Care Information is so important because it’s intended to be, among other things, a proof point that we’re not just talk. We are willing to look at things that aren’t working and fix them because it’s for the good of our patients, your patients and for the good of the practice of medicine.

 

The President’s Podium: A Renewed Effort on HIT

Posted in Electronic health records, Electronic Medical Records, Health IT, meaningful use on May 20th, 2016 by MMS Communications – 1 Comment

by James S. Gessner, M.D., President, Massachusetts Medical Society

Physicians well know the rapid advance of information technology in medicine over the last Gessner Cropdecade.  Pushed by federal and state regulations and requirements, the adoption of electronic medical records has been swift. Today, some 90 percent of physicians in Massachusetts use some form of electronic medical records.

While health information technology (HIT) arrived with great promise and adoption has been quick, widespread acceptance has lagged, and EHRs remain a major concern among physicians of all specialties. Among the most contentious issues: interoperability, clinical workflow efficiency, and the myriad demands of reporting patient data as required by Meaningful Use and the Physician Quality Reporting System, among others.

Some physicians have embraced HIT; they see it as a way to reduce medical errors, streamline workloads, and offer a path to improved outcomes.  Others view it as an impediment to the physician-patient relationship, a huge expense, a tool that consumes too much time, and a source of immense frustration.  Some have even stopped practicing medicine because they found the rules and regulations and operations too onerous.

Health information technology has been a major focus of the Massachusetts Medical Society since the establishment of the MMS Committee on Information Technology (CIT) some 20 years ago. The Committee’s Guide to Health Information Technology has provided useful information and direction for physicians as we struggle through the obstacle courses of HIT and EHRs.

The last year has seen a renewed effort by physicians nationally and locally, to share our concerns about the impact of HIT on physician practices and how we deliver patient care.

In September, MMS hosted an AMA Break the Red Tape Town Hall, to voice concerns about Meaningful Use.  More than 100 physicians attended, and the collective message was clear: EHRs are cumbersome, time-consuming, and hurting productivity.

MMS officials have also met with CMS Acting Administrator Andrew Slavitt on multiple occasions, including a visit last fall, at our suggestion, to Massachusetts and the office of a local family physician.  The visit provided Mr. Slavitt with a first-hand, real-world look at the issues affecting physicians as they work with electronic health records and wrestle with interoperability.  The encounter influenced his thinking about Meaningful Use; Mr. Slavitt has made it clear that EHRs should be patient-centered, physician-focused, and simple.

Our most recent effort was the adoption of a new set of principles governing health information technology.  Proposed by the CIT, the principles were adopted unanimously by the House of Delegates at our May annual meeting.

The essence of the new policy is contained in seven statements. It states that information technology available to physicians should accomplish the following:

  • support the physician’s obligation to put the interests of the patient first;
  • support the patient’s autonomy by providing access to that individual’s data;
  • be safe, effective, and efficient;
  • have no institutional or administrative barriers between physicians and their patients’ health data;
  • promote the elimination of health care disparities;
  • support the integrity and autonomy of physicians; and
  • give physicians direct control over choice and management of the information technology used in their practices.

MMS members may read the complete report of the CIT on these new principles here.

Guided by these principles, MMS will continue to work on health information technology issues and how these tools can improve the practice of medicine – and that means first and foremost a focus on patient care.  HIT does indeed hold promise, but its priority should not be on data collection, but on how it can raise the level of patient care – a goal shared by each of us as physicians.

The President’s Podium appears periodically on the MMS Blog, offering commentary on a range of issues in health and medicine.

 

 

 

May Physician Focus: Colorectal Cancer

Posted in Physician Focus on May 12th, 2016 by MMS Communications – Comments Off on May Physician Focus: Colorectal Cancer

Colorectal cancer is the second leading cause of cancer-related death for both men and women in the U.S., Colorectal Cancerclaiming more than 50,000 lives each year.  The American Cancer Society estimates that 134,000 cases of the disease are diagnosed every year.

Screening for the disease saves lives, but 23 million American adults – about one in three – do not get screened as recommended.

To raise awareness about the condition and the importance of screening, the May edition of Physician Focus features two physicians from the Massachusetts Gastroenterology Association.  Guests are Francis MacMillan Jr., M.D. (photo, center) president of the Association and owner and president of Merrimack Valley Gastroenterology in Haverhill, and Raj Devarajan, M.D., (right) president of Middlesex Gastroenterology and Endoscopy Center in Acton, a board member of the Association, and President of the Medical Staff at Emerson Hospital in Concord.  Hosting this edition is primary care physician Bruce Karlin, M.D. (left)

The physicians discuss the prevalence of colorectal cancer, the suspected causes of the disease, why so many adults don’t get screened, screening guidelines set by the medical groups, the various screening tests available, and the importance of a colonoscopy as a procedure to prevent cancer.

Physician Focus is available for viewing on public access television stations throughout Massachusetts and online at www.physicianfocus.org, www.massmed.org/physicianfocus, and YouTube.