The President’s Podium: Mass. Medicine, After Cost Control
By Ronald Dunlap, M.D., President, Massachusetts Medical Society
Massachusetts entered its second phase of reform with the 2012 passage of Chapter 224, cost control legislation officially titled “An Act Improving the Quality of Health Care and Reducing Costs Through Increased Transparency, Efficiency and Innovation.”
While the first phase, Chapter 54 passed in 2006, was indeed landmark legislation and served as the model for the Affordable Care Act, Chapter 224 alters the state’s health care industry perhaps like no other law.
The changes this law brings are vast, from payment reform to giving the Attorney General new powers in the health care marketplace. Although 224 does include some benefits for physicians (medical malpractice reform for one), other provisions pose significant challenges, particularly for physicians in small practices. Here are two that raise concern.
Health Information Technology (HIT) One of the biggest challenges presented by Chapter 224 is its embrace of health information technology. Physicians will be required – as a condition of licensure – to demonstrate proficiency in all aspects of health information technology by January 1, 2015.
While MMS supports HIT and recognizes its intent to improve patient care, this provision of the law could severely disrupt medical care. Because the statutory language creating the requirement is tied to Federal standards of “meaningful use” (which in turn is tied to participation in Medicare and Medicaid), it raises concerns that strict interpretation of this provision would lead to denial of license renewals for some 26,000 physicians. Our state has a high certification rate for meaningful use, with more than 14,000 physicians having met stage 1 requirements, but nearly 40,000 physicians have a Massachusetts license, and most are not included in the population targeted for meaningful use certification.
Additionally, the costs of establishing HIT can be huge. The outlay for such items as implementation, maintenance, software and hardware upgrades, conversion to Federal ICD-10 codes, training, and data conversion could approach well over half a million dollars for some practices while not including the “opportunity loss of income” from decreased productivity. While the law allows for assistance to providers for HIT, the level of help is unknown, and the financial burden can be crippling to small practices.
The law further requires all providers to implement fully interoperable electronic health records that connect to the statewide health information exchange by January 1, 2017 (a goal not in sight) and imposes penalties for noncompliance. These technologies are not only critical for physicians to practice medicine, but also to participate in quality measurement programs. The specter of this kind of commitment to HIT, however, with its financial outlay, is certain to make physicians pause and think, especially those close to retirement.
MMS has had lengthy discussions with the Board of Registration in Medicine (responsible for implementing the HIT requirement) and has testified in support of legislation to delay this requirement and provide relief to physicians. Our voice has been heard, and we are hopeful such relief will be forthcoming.
Data Collection and Reporting Chapter 224 is equally enthusiastic about data collection and reporting. It creates a “provider organization registration program,” requiring organizations to provide detailed information about their operations: costs, financial performance, utilization, total medical expenses, and patient referral practices, among other information. This data is hard to extract from many EMR systems.
This information will be collected by the Center for Health Information and Analysis (CHIA), a new independent state agency created by 224 that takes over most of the responsibilities of the Division of Health Care Finance and Policy, which was abolished by the law. Physician groups are now required – for the first time – to submit such data. The law contains language focusing on the reporting on risk-bearing groups while exempting smaller groups, but the applicability of this language has not been fully tested yet, so it isn’t clear how reporting requirements will be enforced and upon whom.
On a promising note, CHIA Executive Director Aron Boros told our House of Delegates at the Interim Meeting on December 6 that CHIA’s goal is to gather “reliable and meaningful” information through an “engaged transparent operation.” He believes his agency must be “transparent, open, and collaborative” to build credibility.
The law also stipulates that by January 1, providers must disclose to patients within two working days of their request, how much a proposed procedure or service costs and what the health plan offers as payment.
I am not optimistic that physicians will be prepared within a month’s time to inform patients about specific or estimated costs for all procedures. We are encouraging legislators and the Health Policy Commission to implement the law incrementally, by considering the most expensive procedures first.
HIT and data collection/reporting requirements are but two areas that Chapter 224 dramatically changes. These changes, coupled with constant concerns over Medicare reimbursements as well as added requirements such as those imposed by ICD-10 codes, continue to strain physician practices.
What policymakers and regulators must keep in mind is that, even in a highly sophisticated medical environment like Massachusetts, no less than 64 percent of our physicians are in practices with fewer than 25 physicians. Policies and regulations that burden these practices and reduce their viability will not only affect the quality of care but will also reduce health care access for Massachusetts residents.
The President’s Podium appears regularly on the MMS Blog, offering Dr. Dunlap’s commentary on a range of issues in health and medicine. For a section by section analysis of Chapter 224, click here.