Board of Medicine

Update: Opioid Education Surpasses 20,000 Courses

Posted in Board of Medicine, Drug Abuse, opioids on October 7th, 2016 by MMS Communications – Comments Off on Update: Opioid Education Surpasses 20,000 Courses

RXMonitoringOne of the major efforts MMS has engaged in to address the opioid epidemic in the Commonwealth has been prescriber education.  Our Opioid Therapy and Physician Communication Guidelines, developed by the MMS Task Force on Opioid Therapy and Physician Communication and issued in May of 2015, laid the groundwork in providing guidance to physicians in prescribing opioids to patients.  Those guidelines have been adopted by the Massachusetts Board of Registration in Medicine and incorporated into its comprehensive advisory to physicians on prescribing issues and practices.

Another major contribution by MMS in addressing the epidemic has been the offer of free continuing medical education courses in opioids and pain management for all prescribers. That effort also began in May of last year. A total of 18 courses and modules are available.

A previous blog post in August has discussed how this activity is having a positive impact, helping to reduce opioid prescribing rates across the Commonwealth.  Three separate studies, released in June, July, and August, have catalogued a decline in prescribing rates.

MMS today can report that since the offer of free courses began on May 26, 2015, the number of courses taken has surpassed 20,000.  As of October 7, a total of 20,249 courses have been taken by 7,084 individuals.

Gov. Baker Releases Budget; Board of Registration in Medicine and MassHealth Affected

Posted in Board of Medicine, Uncategorized on March 6th, 2015 by Erica Noonan – Comments Off on Gov. Baker Releases Budget; Board of Registration in Medicine and MassHealth Affected

 

By William Ryder, Esq

MMS Legislative and Regulatory Counsel

Governor Charlie Baker released his first budget this week. Saddled by deficits from the previous administration, particularly in MassHealth spending due to well-documented problems with the Connector, Gov. Baker was faced with significant challenges.

Overall spending is up in MassHealth for Fiscal Year 2016. This is led by managed care line item increases with fee-for-service appropriations slightly down. Both these amounts are based on anticipated demand and projected to maintain access to covered services and maintain current rates. Chiropractic coverage is eliminated for a projected $300,000 saving.

Gov. Baker’s stated commitment to rein in MassHealth spending by confirming eligibility, rather than through across-the-board cuts to providers and legitimate patients, is a reasonable and fair approach that is also federally mandated. Some physicians have expressed concern about reports  that the state could carry over some payments from this fiscal year in FY16. This is often done in state government late in the fiscal year. It does not mean that there will be no payments until July. The governor’s budget proposal is a proposal which must be acted on by the legislature to become law. Usually final passage occurs in June.  Massachusetts State House

Also in the budget is the prescription monitoring program, funded at approximately $1.2 million, a reduction of about $45,000 from last year. It has only six employees to register prescribers, pharmacists, and delegates. As we try to evolve a better PMP, perhaps more resources should be provided to improve the system, provide support staff to participants with concerns, and strengthen the database.

The governor’s proposed budget also included outside sections that would directly impact the Board of Registration in Medicine by placing it within the Mass. DPH and under the authority of the commissioner. The MMS has always supported a fully funded, independent medical board with oversight by the Division of Administrative Law Appeals, the Supreme Judicial Court and the Commissioner of Public Health with some oversight on new regulations. This change was offered by former Senator Richard Moore and rejected in last year’s budget.  MMS will work to maintain the medical board’s independence.

The President’s Podium: Common Sense on EHRs

Posted in Board of Medicine, Electronic health records, Electronic Medical Records, Health IT, meaningful use on September 26th, 2014 by MMS Communications – 1 Comment

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

In its landmark 2001 report,  Crossing the Quality Chasm: A New Health System for the 21st Century, the Institute of Medicine recognized the “enormous potential” of technology to improve health care.  Indeed, of all the changes sweeping throughout healthcare in recent years, perhaps the most revolutionary has been health information technology (HIT).

One area of explosive growth within HIT has been electronic health records (EHRs). The U.S. Department of Health and Human Services noted in May of 2013 that the use of EHRs by doctors and hospitals more than doubled from the previous year, with Massachusetts one of the heaviest adopters.  Statistics from the Office of the National Coordinator for Health IT show that 71 percent of physicians and 80 percent of hospitals in the Commonwealth have adopted EHRs.

Yet, 14 years after the IOM’s report, after billions of dollars spent in federal incentives, and despite skyrocketing adoption, physician acceptance of EHRs appears at best, a mixed bag, at worst, a struggle. Recent efforts are instructive.

In its 2014 Survey of America’s Physicians released this month, The Physicians Foundation found that nearly half of respondents (45.8%) felt that EHRs “detracted from efficiency” and slightly more (47.1%) thought it “detracted from patient interaction.”  More than half (50.5%) believe EHRs “pose a risk to patient privacy.”

Separately, on September 16, the American Medical Association called for an overhaul of EHR systems. “Today’s current EHR products,” said AMA President-Elect Steven J. Sack, M.D., “are immature, costly, and are not well designed to improve clinical care…. The usability of EHRs is a significant driver of physician professional dissatisfaction and a challenge to practice sustainability.” AMA then outlined eight priorities for improving EHR usability to benefit caregivers and patients.

Frustration and dissatisfaction with electronic health records among physicians had surfaced well before the AMA pronouncement, and complaints about EHRs have been increasing as well. The inability of different systems to communicate easily with one another – the “interoperability” issue – remains a drawback.  Perhaps most unsettling, however, is the reality that hazards and risks remain, as the promise of widespread and reproducible gains in patient safety has yet to be fulfilled.

Here in Massachusetts, electronic health records have captured physicians’ attention for quite another reason.  Chapter 224, a law passed in August 2012 that outlined phase two of health care reform for the Commonwealth, included a provision that required physicians to demonstrate “meaningful use” proficiency (which only applies to Medicare and Medicaid) with EHRs as a condition of licensure.  That mandate is to become effective on January 1 of next year.  Without proper interpretation, the law as written could have had severe unintended consequences by disenfranchising over half of the state’s licensed physicians.

Now here’s the good news: The Board of Registration in Medicine has proposed regulations that include a broad set of exemptions for certain license categories.  The Board’s proposal also establishes multiple ways in which physicians could comply with the requirement.

The Board has posted its draft regulations and is accepting comments on them through Friday, October 3 at 5 p.m. MMS offered testimony in strong support of the proposals at the public hearing on Monday, September 29, and I encourage members to add their comments as well. Comments may be submitted via email to Eileen.Prebensen@state.ma.us All comments become public records and will be posted to the state’s website.

MMS has advocated on this issue since the law was passed two years ago, raising the specter of severe disruptions in physician practice and patient access to care.  We are now near a resolution that is advantageous to both physicians and patients.

The Board’s proposal, which addresses all of our major concerns, represents a reasonable, prudent approach to complying with the law, easing physician concerns, and maintaining access to care for patients.

While physician frustration with EHRs is high, it is important to distinguish between problems of technology and problems of policy.  Technological issues are likely to be worked out over time, if only by continued physician persistence and outcry for solutions, as demonstrated by the AMA.

Policy issues, as shown by the Board of Registration in Medicine’s common sense approach to fulfilling the requirements of Chapter 224, are more readily capable of resolution.

MMS, like the IOM, believes that electronic health records do indeed have “enormous potential” for patient care. Our extensive policy on EHRs declares support for them and a desire to work toward improving them, to capture “an opportunity for dramatic benefits to patients in clinical care, research, and the delivery of health care.”

Reaching that potential, however, will require the strong voice of physicians. Whether the issue is one of technology or policy, our local experience has shown how important it is that physicians participate in the conversation.  I urge you once again to review the draft regulations and send in your comments.

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

The President’s Podium: Mass. Medicine, After Cost Control

Posted in Board of Medicine, Electronic health records, Electronic Medical Records, Global Payments, Health IT, Health Policy, Health Reform, Regulation, Uncategorized on December 9th, 2013 by MMS Communications – 1 Comment

By Ronald Dunlap, M.D., President, Massachusetts Medical Society  

Massachusetts entered its second phase of reform with the 2012 passage of DSC_0003 Dunlap 4x6 color 300 ppi_editedChapter 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.  

 

The President’s Podium: The Business of Medical Marijuana

Posted in Board of Medicine, Department of Public Health, Health Policy, Medical Marijuana, Public Health on November 7th, 2013 by MMS Communications – 3 Comments

By Ronald Dunlap, M.D., President, Massachusetts Medical Society

It’s been one year since Massachusetts voters approved a ballot question DSC_0003 Dunlap 4x6 color 300 ppi_editedlegalizing the use of medical marijuana, adding the Commonwealth to a growing list of states allowing it to be used as “medicine.”

MMS had vigorously opposed the referendum, on the basis that the drug lacks the rigorous testing as other FDA-approved drugs; that claims for its effectiveness are not scientifically proven; that it poses health risks of toxins and cognitive impairment; and that a physician’s recommendation of any drug should be a medical decision made in the patient’s best interest based on scientific and clinical evidence and not by public vote. Voter approval notwithstanding, we still hold those positions.

Following the vote, the MMS House of Delegates adopted a revised policy, stating our desire to work with the Board of Registration in Medicine (BRM) and the Department of Public Health (DPH) in developing regulations that would address key issues of a medical marijuana program in the state. Among these issues were patient diagnosis, physician certification, implications for occupational safety and health, inclusion in the Prescription Monitoring Program, and adherence to established professional tenets of proper patient care.

That effort proved fruitful. When DPH issued its regulations, our reaction was positive, saying DPH had done a “thoughtful and responsible job overall” and that the regulations “have taken into account many of our concerns, especially those that call for physician judgment in determining what conditions may qualify and the inclusion of the Prescription Monitoring Program in certifying patients.”

We are now, however, seeing a troublesome sign: the emphasis on medical marijuana has turned from patient care to business opportunity. And it goes beyond the investment or ownership opportunities related to dispensaries.

Entrepreneurs and physicians alike have established internet companies offering to match patients with doctors who will certify their need for medical marijuana. These companies will provide consultations and certifications – for fees ranging from a low of around $50 to upwards of $200. “Renewal fees” may also be charged.

I have publicly raised concerns about such sites.  I told The Boston Globe in September such activity is “working around the edges” of the rules, and I elaborated with the Business Journal of Western Massachusetts in October, saying “people that I call internet opportunists are essentially getting a doctor or list of doctors they feel will certify patients, and simply inviting patients to pay them money as a finder’s fee.”

One of the key regulations, sanctioned by the BRM and adopted by DPH at the urging of MMS, was that a physician should have a “pre-existing and ongoing relationship with the patient as a treating physician” before a patient should receive certification.

The proliferation of what I call these “certification centers” is disturbing; it erodes, if not skirts entirely, the “ongoing relationship” regulation and has the potential for abuse.

The experience in Colorado, which approved medical marijuana in 2000, is instructive. A June 2013 report from the Colorado Office of the State Auditor found “evidence suggesting that some physicians may be making inappropriate recommendations.” Twelve physicians had certified half of the 108,000 registered patients, and one had registered more than 8,400.

Despite its legality, many unknowns remain about medical marijuana, including appropriate dosage and frequency of use for conditions, strength of the drug from various sources, and clinical effectiveness. The Massachusetts model does not include any provisions for dosage, administration, or other basic elements that would be contained in a prescription for another medication.

Further, we are uncertain of the liability issues and whether insurers will cover defense costs and judgments in cases involving certifications. The drug also remains prohibited by the federal government, raising more questions about physician licensing by the Drug Enforcement Administration, which, contrary to press reports, has firmly stated that it has not relaxed its policy on medical marijuana.

Each physician, after weighing the risks and reviewing a number of considerations, will make his or her own decision about certifying patients and whether it’s in the best interests of both patient and physician. Some are already doing so.  That is another of the many decisions to be made within the physician-patient relationship.

That the business of medical marijuana has taken hold is no surprise; it was inevitable and likely will always be there. But, as physicians, let’s do what we can to refocus the issue back where it belongs: on patient care and patient safety.

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

Changes at the Board of Registration in Medicine

Posted in Board of Medicine on December 18th, 2012 by MMS – 1 Comment

By Richard V. Aghababian, MD
MMS President

The Board of Registration in Medicine, the state agency that oversees the licensure of physicians, is undergoing some major changes. With the departure of Dr. Stancel Riley as executive director, we understand that the board will be naming an interim director this week.

The new chair of the board, Dr. Candace Sloane, has reached out the MMS to discuss what lies ahead.  She visited the MMS to hear our concerns and questions, and we anticipate several meetings in the coming weeks and months to work on issues of mutual interest. She also asked for input on the three unfilled positions on the board,  which are a high priority to fill.

One of the areas to discuss is the recent appointment of Kathleen Meyer.  The membership of the board has traditionally included attorneys and retired judges, and we saw that was a good thing. They understand the need for high legal and ethical standards, and strongly appreciate the value of due process in the board’s operations.

However, the appointment of Kathleen Meyer has prompted widespread concerns among many of my colleagues. Ms. Meyer has personal and professional affiliations with Lubin and Meyer, one of the leading malpractice law firms in the state.

The potential for conflicts of interest are obvious. We’re deeply concerned about her impartiality in cases that reach the board, as well as her possible early access to unvetted complaints filed by patients against physicians – patients who could be clients of Lubin and Meyer and other malpractice firms.

But simply recusing herself from problematic cases wouldn’t solve the entire problem. She is in a position to strongly influence the discussion and implementation of many important public policy issues, most of which would affect or even benefit Lubin and Meyer, both directly and indirectly.

How will these issues be addressed?

The board’s job is to protect the safety of the public. This duty must be balanced with the highest regard for physicians’ right to due process in all disciplinary proceedings – a right that has been strongly affirmed in case law.  Under intense public scrutiny, the board in the past has executed its mandate and balanced its imperatives in a thoroughly professional and competent manner. Its situation bears no resemblance to the issues that have afflicted other state oversight agencies, such as the Board of Pharmacy.

We believe in a strong, effective and independent Board of Registration in Medicine. In fact, we supported and helped promote changes in its funding that buffer its members and staff from the fickle winds of politics. This is good for public safety, and it’s good for the profession of medicine.

15 Years of Physician Profiles: A Massachusetts Success Story

Posted in Board of Medicine on March 21st, 2012 by MMS – 1 Comment

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.

Five Ways You Can Meet the State’s New CME Licensing Requirements

Posted in Board of Medicine, CME, End of Life Care on January 20th, 2012 by Erica Noonan – Comments Off on Five Ways You Can Meet the State’s New CME Licensing Requirements

The state Board of Registration in Medicine notified physicians this week of new regulations that require them to complete CME courses in pain management and end of life care during the license renewal or obtaining a new license.

Pain management: Effective Feb. 1, physicians who prescribe controlled substances (Schedules I through VI) must complete at least three credits of education and training in pain management and opioid education.

MMS and the Boston University School of Medicine offer two courses to help physicians fulfill that requirement:

End-of-life care: Also effective Feb. 1, all physicians seeking a new or renewed license must take two CME credits in end of life care. The credits can qualify as either category 1 or category 2, and may be counted as risk management credits.

The MMS offers three online courses to fulfill this requirement:

The pain management education requirement was created by the Legislature in statute enacted in 2010. In public testimony, the MMS unsuccessfully opposed that requirement.

Mandatory education in end-of-life care was imposed by the Board of Registration in Medicine (BRM) following the recommendation of a special commission. It was not a legislative mandate, and the MMS opposed the inclusion of this condition for licensure based solely on the BRM’s perception of the significance of the issue.

BRM Executive Director Stancel Riley, MD, is scheduled to meet the MMS Board of Trustees in March to discuss these and other new licensing regulations.

 

 

Complete Rewrite of the Board of Registration in Medicine’s Regulations is Underway

Posted in Board of Medicine, Regulation on July 29th, 2011 by MMS – Comments Off on Complete Rewrite of the Board of Registration in Medicine’s Regulations is Underway

The state Board of Registration in Medicine has released a draft copy of newly revised proposed regulations governing licensing and the practice of medicine.

The new proposals come in three sections of 11, 66 and 23 pages respectively, and deal with discipline, licensing and the practice of medicine, and patient care assessment programs.

Hearings are likely in September. The MMS is still reviewing the regulations but it is clear that every aspect of the Board’s processes is included in the rewrite.

  • The regulations specify mandatory CME requirements in pain management, competence in electronic medical records and end of life care. The first two of these were required in some form by the state legislature.
  • License categories now include: retired, inactive, volunteer, administrative, restricted, full, limited and temporary.
  • Health care facilities are defined as anywhere medicine is practiced.
  • The definition of the practice of medicine now includes telemedicine when the patient information is generated in the Commonwealth.
  • A new process for CMEs is created by using the term continued professional development or CPDs instead. The Board gives itself the authority to approve activities, courses etc which may qualify for mandatory CPD hours.
  • Specifics on compliance with audits for continuing education requirements are listed.
  • Specifics on allowable corporate forms for the practice of medicine are included on page 43 of section 2.
  • Provisions are outlined for renewals of licensure without automatic revocation in limited circumstances where a renewal application is not complete.

Over the last decade, the Board has periodically reopened the regulatory hearing process but never completed a comprehensive rewrite and update. Previous proposed changes brought a fire storm of opposition and criticism from the medical community based primarily on concerns that the Board was overreaching its authority and poorly designing its regulatory framework in a variety of areas.

The Board’s regulatory structures are enormously complex and complicated by legal decisions and precedents. The MMS will continue to review the complex proposals with an eye towards our testimony and advocacy in the Fall. Comments on the proposals or specific questions may be sent to William Ryder, MMS Director of State Legislative and Regulatory Affairs, at wryder@mms.org.

— William Ryder