August Physician Focus: Advance Care Planning

Posted in End of Life Care, Palliative Care, Physician Focus, Uncategorized on July 31st, 2014 by MMS Communications – Be the first to comment

Physicians are increasingly recognizing the importance of advance care planning – preparation for the end-of-life -  and as the subject gains more public attention, more patients are being motivated to talk about the issues.

The August edition of Physician Focus shares the physician’s perspective on this topic with two members of the Massachusetts Medical Society’s Committee on Geriatric Medicine.

Eric Reines, M.D., (photo, center) a geriatrician with Element Care in Lynn and chair of the committee, and Beth Warner, D.O., (right) a consultant geriatrician with Cooley Dickinson Health Care in Northampton and committee member, join host and primary care physician Bruce Karlin, M.D. (left) to discuss the basics of advance care planning.

Among the topics of conversation are the importance and advantages of planning, when it should begin, how to start the process, and the physician’s role in the process. Healthcare proxies, medical orders for life-sustaining treatment, and hospice and palliative care are also included in the discussion.

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

The President’s Podium: Tracking Prescription Drug Abuse

Posted in Department of Public Health, Drug Abuse, opioids, Public Health on July 17th, 2014 by MMS Communications – Be the first to comment

By Richard S. Pieters, M.D., President, Massachusetts Medical Society

The Centers for Disease Control’s just-released state-by-state report on opiate abuse has cast a bright new light on this serious and potentially deadly problem.

Saying that an “increase in painkiller prescribing is a key driver of the increase in prescription overdoses,” CDC noted that prescribers wrote 259 million prescriptions for painkillers in 2012, and that 46 people die from prescription overdoses every day. That prompted CDC Director Dr. Tom Frieden to capture the paradox: “All too often, and in far too many communities, the treatment is becoming the problem.”

Massachusetts ranked in the top 10 in prescribing long-lasting painkillers, but 41st in overall prescribing of opioids.  Rankings, however, are only a reference point, as volume itself is insufficient to indicate whether overprescribing or under prescribing is occurring.  And rankings matter little when counting the human toll: in Massachusetts alone, 688 residents died from opiate overdoses in 2012, and more than 200 additional lives have been lost since November 2013, according to the Massachusetts Department of Public Health (DPH).

Multiple responses are under way in the Commonwealth: The Governor has formed an Opioid Task Force, the legislature has filed bills, DPH launched Opioid Overdose Education and Naloxone Distribution Program, and police and fire departments are now carrying naloxone.

Regionally, five New England governors agreed to collaborate, and nationally, the U.S. Senate has announced the formation of a Prescription Drug Abuse Working Group.

Physicians are adding their voices as well. MMS immediate past president Dr. Ronald Dunlap offered his perspective in April, and American Medical Association President Dr. Robert M. Wah, following the New England governors’ announcement in June, shared a five-point proposal to combat prescription drug abuse.

The CDC is focusing attention on overprescribing by healthcare providers, and while others continue to see physicians as part of the problem, thefts from pharmacies and diversion from families and friends remain major contributors to the problem, as is the influx of heroin into Massachusetts and New England.

A critical need in responding to this crisis is getting better data. We should know the sources of the drugs – how many come from prescriptions, how many from thefts, how many are diverted from home medicine cabinets – to develop responses.

Better data is available through the state’s Prescription Monitoring Program (PMP), a program MMS helped to establish more than 20 years ago.  It’s one of the best tools we have to track prescription use, and one CDC urges all states to use.  The experiences of New York and Tennessee are testimony to the effectiveness of such programs.

In Massachusetts, however, the program has yet to fulfill its promise.

A well-run PMP has four purposes: (1) identifying patients who get schedule II and III prescriptions from multiple doctors; (2) identifying prescribers who inappropriately write many prescriptions or write prescriptions for high dosages; (3) providing a clinical review of those patients and prescribers, to determine what interventions might be necessary; and (4) facilitating research in discovering trends, practices, and problems.

To achieve the program’s full benefit, two things must occur: (1) the PMP must allow all prescribers and dispensers access to up-to-the-minute data on individual patients, and (2) the state must reform its structure to devote resources to the clinical analysis of data and to streamline outreach to providers.

Further, a re-energized medical review board, created as part of the original PMP but subsequently reduced in its role, will give an added boost to the effort.  The board can determine patterns of abuse, propose needed interventions, and should be charged with responsibility for referral of such activity to licensing boards or law enforcement authorities.

For the individual clinician, the monitoring program should be a tool seamlessly incorporated into clinical decision making, but it should never impede appropriate patient care.  One of the most difficult tasks for physicians in patient care is balancing the alleviation of pain and the risks of addiction, and we must recognize that patients who experience severe pain will always require treatment and should be able to get relief.

An improved PMP, with real-time data, with all prescribers participating, and with accurate and timely data analysis, should be regarded as the cornerstone of our collective efforts to address prescription drug abuse.  It’s time for that to happen, and physicians stand ready to help.

Addiction is a major public health problem that needs prevention and treatment. Prevention requires the use of all pain management tools, including such methods as physical therapy and acupuncture. We should use the PMP as a starting point to engage other stakeholders to develop a comprehensive strategy for chronic pain management, with the hope of less need for opioids and thus less addiction. Such actions should also lead to more compassionate and enlightened treatment of addiction.

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

 

Beware of Insurers’ Shift to Credit Card Payments

Posted in practice management on July 10th, 2014 by MMS – Be the first to comment

Credit cardSome health plans have been issuing physician practices consumer credit cards or virtual credit cards as payment for their services instead of depositing funds directly to bank accounts. According to the AMA, this relatively new trend can cut physician pay by as much as 5 percent after transaction fees.

What can practices do?

If a practice receives a virtual credit card payment, the practice can call the payer and ask them to remit payment through a more traditional mechanism. Practices can demand that payers issue payments via EFTs deposited directly into their bank account. Other suggestions for practices include:

  • Review and evaluate payer contracts to determine whether your practice is required to accept credit cards as a method of payment.
  • Understand merchant card agreements and associated fees if your practice decides to accept credit cards. You also may want to ask if payers are using credit card reward programs that give cash back.
  • Request payment using the health care EFT standard known as ACH CCD+. This transaction, approved by the Health Insurance Portability and Accountability Act, is less costly to payees than credit card transactions.

More information

Physician Focus for July: Boards of Health

Posted in Health, Physician Focus, Public Health on July 1st, 2014 by MMS Communications – Comments Off

In 1799, Paul Revere was appointed chairman of the Commonwealth’s first Board of Health in Boston and was given broad authority to control deadly epidemics and environmental contamination. More than 200 years later, today’s health boards, while charged with many more responsibilities, have much the same purpose: to provide for the public’s health and safety.  They have been given the obligation and authority by the state legislature to protect the public health and welfare, similar to powers given to local police and fire departments.

The July episode of Physician Focus examines how public health efforts are conducted at the community level with senior executives of the Massachusetts Association of Health Boards (MAHB).  The program discusses the responsibilities of the boards, their enforcement powers, how they’re managed and operated, the challenges they face in performing their duties, how they balance individual rights and behaviors while maintaining standards of health and safety for the entire community, and how they relate to other local and state agencies.

Guests are Christopher Quinn, M.D. (photo, center) and Ms. Cheryl Sbarra (right).  Dr. Quinn is Director of Occupational Health Services at Sturdy Memorial Hospital in Attleboro, Mass., a physician with the Attleboro Health Department, and President of MAHB. Ms. Sbarra is the staff attorney for MAHB and provides legal consultation, policy guidance and technical assistance to boards of health and municipal governments throughout the Commonwealth.  Hosting this edition is B. Dale Magee, M.D. (left), MMS past president.

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

Physician-Experts on Medical Marijuana: Not a First-Line Therapy

Posted in Medical Marijuana on June 20th, 2014 by Erica Noonan – Comments Off

More than 100 physicians gathered recently at MMS headquarters to take part in a history-making discussion about what the legalization of medical marijuana in the Commonwealth means to them as healthcare providers.

Throughout the half-day CME event, Medical Marijuana: Regulations, Responsibilities, and Communication, physician panelists presented various clinical scenarios in which marijuana certification could be considered. One of the experts, Alan Ehrlich, MD, an assistant professor of family medicine at University of Massachusetts Medical School, polled the audience about whether they’d certify patients in given circumstances. Though physicians’ opinions varied as to how they’d approach each circumstance, two consistent themes emerged.

Medical Marijuana is Not  a First-Line Therapy

 “Marijuana does not fix MS,” emphasized Ehrlich. “Make sure they’re getting treated for the underlying disease.” Multiple sclerosis is not the only qualifying condition in which this notion applies. Whether a patient is suffering from cancer, glaucoma, ALS, MS, or chronic pain, physicians must determine whether patients are undergoing treatments to manage their disease before turning to marijuana to help manage symptoms of their disease, or in some cases side effects of other treatments.

When it comes to marijuana several panelists noted, people often hold biases at extreme ends of a spectrum: that it’s either completely harmless or a drug that sends users on the road to ruin.

Neither of those absolutes hold true, but there are real risks to certain patients that physicians need to take into account, according to Kevin P. Hill, MD, MHS, director of Substance Abuse Consultation Service, Division of Alcohol and Drug Abuse at McLean Hospital and an assistant professor of Psychiatry at Harvard Medical School.

For example, an estimated nine  percent of adults who use marijuana become addicted, which translates to about 2.7 million people out of current users. In addition, patients predisposed to mental-health problems may be prone to marijuana use triggering a worsening of those issues.

MDs Must Consider the Context and “Whole” Patient

Ultimately, the question isn’t whether marijuana use is risky, noted Ehrlich, but how dangerous it may be when compared to other risks, such as a patient not being able to stick with therapy due to intolerable side effects. Alternatively, if a patient drives for a living and has a condition that would call for using marijuana during the day, the relative risks increase.

As with recommending any treatment for patients, physicians have to look at it in the full context of patients’ lives, noted Riley M. Bove, MD, a neurologist with Partners Multiple Sclerosis Center at Brigham and Women’s Hospital. “We always have to look at the patient as a whole person,” she said.

 –Debra Beaulieu-Volk

Links to videos:

 

Alan Ehrlich, MD, assistant professor of family medicine at the University of Massachusetts Medical School, discusses the evidence of the efficacy and harms of medical marijuana.

 

Kevin P. Hill, MD, MHS, director of the Substance Abuse Consultation Service at McLean Hospital in Belmont, Mass., discusses substance abuse, addiction, and other adverse effects of marijuana.

 

Riley M. Bove, MD, neurologist and faculty member of the Partners Multiple Sclerosis Center, discusses the evidence regarding the use of marijuana for patients with multiple sclerosis.

See all videos and slide slows from the half-day MMS CME event, Medical Marijuana: Regulations, Responsibilities, and Communication

 

AMA President: A Prescription for Opiate Abuse

Posted in Drug Abuse, opioids, Public Health, Uncategorized on June 20th, 2014 by MMS Communications – Comments Off

Attention and activity directed at the persistent problem of opiate abuse are continuing to increase in the Commonwealth, as policymakers, regulators, legislators, and public health officials propose solutions and programs to address the epidemic.

The latest effort is a collaboration of five New England Governors, who announced on June 17 a unique agreement to work together across state borders to address the problem of opiate abuse, focusing on the monitoring of prescriptions and increasing addiction treatment.

The agreement prompted a thoughtful piece from American Medical Association President Robert M. Wah, M.D. Published online in The Boston Globe on June 18,  Dr. Wah offered a five-point prescription to fight prescription drug abuse, emphasizing treatment and prevention.

The piece adds to the perspective of Massachusetts physicians, previously expressed by MMS Immediate Past President Ronald Dunlap, M.D.  in April in newspapers across the Commonwealth.

Most important, Dr. Wah’s commentary raises the physician’s voice on a critical national issue, offers the assistance of the nation’s leading physician organization in working with governors and legislatures to reduce prescription drug abuse, and demonstrates that physicians seek to be part of the solution.

June Physician Focus: Infectious Diseases

Posted in Health, Physician Focus, Public Health, Uncategorized on May 30th, 2014 by MMS Communications – Comments Off

Measles has hit a 20-year high in the U.S., and mumps and whooping cough are likewise reappearing with disturbing frequency.  Warm weather approaches, raising the threat of mosquito- and tick borne illnesses, and new, emerging diseases such MERS and dengue are now reaching the U.S.

A stubborn resistance to immunization, global travel, and the seasonal return of mosquitoes and ticks are contributing to an increased threat of infectious disease this year.

The June episode of Physician Focus highlights several common and emerging infectious diseases, discussing their origins, symptoms, effects on health, and the steps patients can take to safeguard themselves from infection.  The conversation also covers the critical role vaccines play in preventing infectious diseases and what people should do prior to international travel to minimize the risk of disease.

The guest for this program is infectious disease specialist George Abraham, M.D., M.P.H., F.A.C.P. (seated, photo), who joins program host B. Dale Magee, M.D., past president of the MMS for the discussion.  Dr. Abraham is Associate Chief of Medicine at Saint Vincent Hospital in Worcester, Professor of Medicine at the University of Massachusetts Medical School, and Massachusetts Governor for the American College of Physicians.

Dr. Abraham earned a master’s degree in public health in infectious disease epidemiology from the Johns Hopkins School of Public Health and has served as a World Health Organization fellow in HIV disease in Uganda and as an infectious disease fellow at the Communicable Disease Center in Singapore.

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

Recapping a Busy Year: MMS Health Care Advocacy in 2014

Posted in Annual Meeting 2014, Electronic health records, Health Reform, meaningful use, Medical Marijuana, Medicare, Payment Reform on May 15th, 2014 by MMS – Comments Off

Ronald W. Dunlap, MD, president of the Massachusetts Medical Society, kicked off the Society’s 2014 Annual Meeting with a review of five significant advocacy issues from the 2013-14 year:

  • Medicare payment
  • ICD-10 deadlines
  • Regulatory overreach
  • State regulations on EHRs
  • Medical Marijuana

 

Medical Marijuana: One Physician’s Take

Posted in Medical Marijuana, Primary Care, Public Health on May 13th, 2014 by MMS Communications – Comments Off

Long after the vote of the people was recorded, the implementation of medical marijuana in Massachusetts continues to raise multiple questions for many.  One of the most important is this: how vigorously will physicians consider marijuana as a medicine and participate in certifying patients?

While some physicians have already begun to certify patients, others are saying no.  Major impediments to physician participation include the lack of scientific evidence supporting the effectiveness and safety of the drug for the majority of its purported uses and their reluctance to start patients on treatment regiments with which they have no experience or training.

On May 3, the Daily Hampshire Gazette in Northampton published an editorial stating that “The step of certification is the most important one patients take in a multi-step process to obtain medical marijuana.”  The paper, noting that physicians for the most part are shying away from certifying patients, had a clear message for physicians: “We urge doctors to be bold. It seems cruel and inhumane to withhold treatment of a legal drug to people who are suffering and with it may find relief.”

Dr. Alan Berkenwald, a Northampton physician who practiced primary care in the area for 25 years before becoming a hospitalist at Cooley Dickinson Hospital, responded, and the Gazette published his commentary on May 7.  Read Dr. Berkenwald’s, Why I won’t prescribe medical marijuana, here.

 

Perspective: CMS Release of Physician Payments

Posted in Health Policy, Health Reform on May 7th, 2014 by MMS Communications – Comments Off
DSC_0003 Dunlap 4x6 color 300 ppi_edited

MMS President Ronald Dunlap:   perspective needed on Medicare payments.

When the Centers for Medicare and Medicaid Services (CMS) last month  released its physician payment data for 2012, the agency described it as a major step forward for health care transparency, and CMS administrators and Congressional representatives alike extolled the virtues of making such information public.

The proposed action wasn’t without controversy. Prior to its release, nearly 100 national, state, and specialty medical societies signed on to a letter sent in September 2013 to CMS citing physician concerns about the release of raw data and opposing its release, saying it “should be limited for specific purposes and with appropriate safeguards.”

The letter further stated that the societies welcomed “the opportunity to work with CMS to improve meaningful and appropriate access to this information and recognize the potential value and importance of Medicare physician claims data,” and it encouraged CMS to partner with physicians to develop policies that will “promote the reliable and effective use of this information” and cited many concerns physicians had about releasing the data.

CMS released the raw data on April 9, and, predictably, news coverage was widespread across the nation.  The Wall Street Journal wrote that “The trove of Medicare data released Wednesday shows a wide cast of characters in the top ranks of the highest-reimbursed doctors, and reveals as much about the limits of the newly public billing records as it does about medical practice.”

The New York Times noted the limits of the data as well, writing that “Many other doctors worried that the data released was incomplete and often misleading. In some cases, enormous payments that seem to be going to one doctor are actually distributed to multiple others. But the data tables do not reveal that the money was shared.”  Much of the news coverage in the Commonwealth focused on local physicians receiving large payments.

Reaction from physicians was mixed; some were outraged, some were surprised, some were resigned to the data’s release as part of the continuing trend in transparency.  CMS released the data with a minimum of explanation, saying only that there may be legitimate reasons why doctors get high Medicare payments. But physician payments, from whatever source, are part of the highly complex nature of health care spending and require some perspective for better understanding.

MMS President Dr. Ronald Dunlap offers such a perspective in this commentary, published May 2 on WBUR’s CommonHealth website.