Primary Care

October Physician Focus: Telemedicine

Posted in behavioral health, Health, Health IT, Physician Focus, Primary Care on September 30th, 2016 by MMS Communications – Comments Off on October Physician Focus: Telemedicine

Technology has been rapidly changing the practice of medicine, and one of the fastest growing areas is telemedicine, using such means as video platforms, text messaging, patient portals, and health “apps” that permit communication between physician and patient.

From left: Dr. Dale Magee, Dr. Adam Licurse, Dr. Steven Locke

From left: Dr. Dale Magee, Dr. Adam Licurse, Dr. Steven Locke.

The October edition of Physician Focus takes a look at this emerging area of medicine with Adam Licurse, M.D., a primary care physician and Associate Medical Director of Brigham and Women’s Physicians Organization and Partners Population Health Management, and psychiatrist Steven Locke, M.D., Chief Medical Officer and Co-Founder of iHope Network and member of the MMS Committee on Information Technology.  Hosting this edition is Dale Magee, M.D., a past president of MMS.

The discussion examines the impact of telemedicine on physicians and patients, its advantages and shortcomings, how the field of mental health has acted as a pioneer in the field, how it can help to ease the stigma that prevent patients from getting care, and the concerns clinicians still have with the application of telemedicine in patient care.

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.

July Physician Focus: Men’s Health

Posted in Physician Focus, Primary Care on July 1st, 2016 by MMS Communications – Comments Off on July Physician Focus: Men’s Health

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.

Ethics Forum: Patient Experience and Satisfaction

Posted in Ethics Forum, Primary Care on May 5th, 2016 by MMS Communications – Comments Off on Ethics Forum: Patient Experience and Satisfaction

A growing part of the ever-changing healthcare landscape is measuring patient satisfaction. Hospitals and physicians, more and more, are being rated and ranked based on a patient’s experience – what they think of the care they get from their individual physician, what they think of their stay in a particular hospital. Reputations are at stake, as are reimbursements and payments.

Surveys and publication of patient satisfaction with providers of all kinds are growing in number. And they’re here to stay.

That was part of the message from the MMS Ethics Forum on Thursday, May 5 presented by the Committee on Ethics, Grievances, and Professional Standards as part of the 2016 MMS Annual Meeting.

The Forum, entitled Patient Satisfaction Surveys: Utility and Unintended Consequences, featured presentations from Thomas Lee, M.D., Chief Medical Officer of Press Gainey and former CEO for Partners Community HealthCare, Inc., and Allen Kachalia, M.D., J.D., a general internist and Chief Quality Officer at Brigham & Women’s Hospital. Below, are the main points from their presentations.

Ethics-Thomas-Lee

Dr. Thomas Lee

Dr. Lee recognized that patient measurement can lead to unwanted changes or unintended consequences, but also acknowledged that not measuring patient experience means “giving up on the idea of improvement.” The challenge, he said, was “to invest thought, time and energy in preparing people to receive data [of measurement], and it’s a challenge worth taking on.”

Patients are afraid, he noted, not just of their diseases or the therapies they may have to undergo, but of the lack of coordination by the medical community, that, as he bluntly stated, “we don’t have our act together” in caring for patients.

Dr. Lee, however, ended on a positive note. The keys to proper and well-accepted measurements, he said, are within our control: better care coordination, more empathy, and improved communication with the patient. The good news, he said, is that those drivers of patient satisfaction are consistent with the professional values of physicians.

Ethics-Allen-Kachalia

Dr. Allen Kachalia

Dr. Allen Kachalia said that legitimate issues exist in accurate measurement.  The rankings are based on inexact science, response rates are generally too low, financial incentives are motivating the wrong behaviors, and measurement is one more item for physicians to manage. Yet his message was clear: patient satisfaction and the public reporting of patient experiences are here to stay.  “All of us want to be the best,” he said, “but there’s no way to know if we are the best without measurement.” The key, he said, is to balance patient experience with quality of care. Physicians must “embrace measurement and be transparent,” Dr. Kachalia stressed, and “offer solutions to the poor metrics” that exist in measurement today.

 

November Physician Focus: Managing Your Chronic Disease

Posted in Health, Physician Focus, Primary Care on October 31st, 2014 by MMS Communications – Comments Off on November Physician Focus: Managing Your Chronic Disease

Chronic diseases such as asthma, heart disease, arthritis, and diabetes affect about half of all American adults, and their incidence is likely to increase as members of the baby boom generation reach the ages when chronic diseases become more prevalent.

Traditional care for these conditions has centered on the physician’s role, but a new model of care is emerging: that of patient self-management, where patients, in partnership with their physicians, become their own principal caregiver.

The November edition of Physician Focus examines this new model of care with representatives from the Healthy Living Center of Excellence. Robert Schreiber, M.D., (photo, right), Medical Director, and Jennifer Raymond, J.D., M.B.A., (center) Director of Evidence-Based Programs, join host B. Dale Magee, M.D., (left) a past president of MMS, in discussing the purpose, goals, and benefits of these self-management programs and how physicians and patients can participate.

The Healthy Living Center of Excellence is a collaborative effort of Elder Services of the Merrimack Valley in Lawrence, Mass. and Hebrew Senior Life in Boston. Through regional-based efforts with community organizations, health care providers, health plans, government, and foundations, the Center offers free programs in community-based settings from seven regional centers throughout Massachusetts that help patients 18 years of age and older with chronic conditions manage their own care.

Results of these programs have shown that patients have better health outcomes, better care experiences, better communication with their providers, and are much more able to manage their conditions.

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.

Medical Marijuana: One Physician’s Take

Posted in Medical Marijuana, Primary Care, Public Health on May 13th, 2014 by MMS Communications – Comments Off on Medical Marijuana: One Physician’s Take

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.

 

April Physician Focus: Health Care Disparities

Posted in Health, Health Policy, Medicine, Physician Focus, Primary Care on March 31st, 2014 by MMS Communications – Comments Off on April Physician Focus: Health Care Disparities

A dozen years ago, the Institute of Medicine released its groundbreaking report on health care disparities, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. That report concluded that wide differences exist between racial and ethnic minorities and whites in access to health, availability of insurance, and the quality of care they received.

The IOM report made public a topic that today still commands the attention of the medical community, and it’s the subject of the April episode of Physician Focus.

Guests for the show are Ronald Dunlap, M.D. (photo, center), President of the Massachusetts Medical Society, and Milagros Abreu, M.D., M.P.H. (right), Vice Chair of the MMS Committee on Diversity in Medicine and Founder and President of the Latino Health Insurance Program in Framingham. Alice Coombs, M.D., (left) past president of MMS and a member of the American Medical Association’s Commission to End Health Care Disparities, serves as host.

Among the topics of conversation by the physicians are the causes of health care disparities, their consequences on the health outcomes of patients, and the steps both physicians and patients can take to reduce these differences and improve care.

April’s Physician Focus is part of a renewed attention to the issue of health care disparities by the Medical Society, as outlined by Dr. Dunlap in his blog post of March 28 (below).

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 www.massmed.org/itunes.

The President’s Podium: It’s Time for Equal Treatment

Posted in Health, Medicine, Physician Focus, Primary Care on March 28th, 2014 by MMS Communications – 1 Comment

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

When the Institute of Medicine published its groundbreaking report on DSC_0003 Dunlap 4x6 color 300 ppi_editedhealth care disparities in March of 2002, the topic touched a raw nerve in the medical community. Almost overnight, health care disparities became a top priority for medical professionals and policymakers alike.

Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care disclosed what all of us consider to be a distressing and unacceptable aspect of health care in America: that racial and ethnic minorities receive poorer quality medical care than whites, even when such factors as insurance coverage, ability to pay, and access to care were equal among the groups.  It is also quite clear that socioeconomic status and poverty contribute to health care disparities.

More than a decade after the IOM’s report, health care disparities still commands our attention, a topic increasing in importance, as our population continues to undergo demographic changes.

For years, the Massachusetts Medical Society has been one of the leading voices in the effort to reduce health care disparities in the Commonwealth. Our members have worked to educate our colleagues about the issue. We have testified before the state legislature in support of bills to reduce disparities in care. We have examined the ethical aspects of disparities, and our patient education efforts have focused on the subject.

I am proud to say we are continuing our efforts.

Our 2014 Public Health Leadership Forum, The Impact of Health Care Reform on Health Care Disparities (occurring Friday, April 4 from 9 a.m. to 1 p.m.) brings together some of the nation’s best health care experts to discuss how reform efforts may affect disparities in care. This forum, moderated by Lenny Lopez, M.D., Chair of the MMS Committee on Diversity in Medicine, adds a new dimension to our efforts on health care disparities, as it is being conducted in collaboration with the Commission to End Health Care Disparities.

The Commission was formed in 2004 by the American Medical Association and the National Medical Association, with the National Hispanic Medical Association joining soon thereafter, to respond to the IOM’s report. It has become the nation’s leading advocate to reduce disparities in care.  The MMS has had and continues to have a seat at the table: Alice Coombs, M.D., MMS past president and past chair of the Committee on Diversity in Medicine, has represented MMS on this committee for several years.

Among the scheduled participants in our Leadership Forum are Commission Co-Chairs Jeremy Lazarus, M.D., immediate past president of the American Medical Association, and Lawrence Sanders, M.D., president-elect of the National Medical Association. Besides looking at the effect of reform on disparities in care, participants will also address how changes in policy and practice and such areas as pay for performance and technology can reduce disparities in care.

Our continuing efforts also include a new dedicated web page on health care disparities that provides research and reports on the topic, resources and activities to identify and reduce disparities, strategies and tools to help eliminate them in the physician’s office, and information on the role of a diverse physician workforce in addressing differences in care.

And to bring the message beyond the medical profession, our April episode of Physician Focus, the MMS’s monthly patient education television program, discusses the issue in depth, describing the causes and consequences of health care disparities and what physicians and patients can do to reduce these differences and improve care. Hosting this show is Dr. Coombs, with Milagros Abreu, M.D., Vice Chair of the Committee on Diversity in Medicine, joining me as a guest. An accompanying print article is also being distributed to media across the state.

Twelve years after the Institute of Medicine’s report, we are making progress in reducing disparities, certainly more slowly than we would like, but making progress nonetheless. It is clear that reducing disparities will involve the efforts of everyone in health care – all physicians, providers, payers, and policymakers, and, yes, even patients.

My hope is that our upcoming efforts will signify a renewed commitment to equal treatment. It is a goal worth pursuing and achieving, and it’s time is long overdue.

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

  

 

The President’s Podium: A Quiet Triumph

Posted in Primary Care, Public Health on February 19th, 2014 by MMS Communications – Comments Off on The President’s Podium: A Quiet Triumph

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

It happened on a day when everyone’s attention was DSC_0003 Dunlap 4x6 color 300 ppi_editedfixed on the coming of yet another winter storm.  Perhaps that’s why it received little, if any, attention.  But an important piece of legislation affecting the state’s public health –and especially the health of our children – has quietly become law.

On February 12, Governor Patrick signed into law the Massachusetts Childhood Vaccine Program, a long-standing priority of the MMS and the Massachusetts Chapter of the American Academy of Pediatrics (MCAAP).  Both organizations had pushed hard for passage of the bill, which was proposed by Senator Richard Moore of Uxbridge.

Following the Governor’s signature, MCAAP President John O’Reilly, M.D. and I issued a joint statement, saying that the law represents “a critical investment in the future health of the children of the Commonwealth.”  Indeed it does.

The new law guarantees access to all recommended vaccines for all children in the Commonwealth and establishes two key programs:  A Vaccine Purchase Trust and a Massachusetts Immunization Registry.

The Vaccine Purchase Trust Fund will pay for the distribution childhood vaccines through a public-private collaboration by charging an assessment on Massachusetts insurers for the cost of all vaccines for the children covered in their plans.  The vaccines can then be purchased through the Department of Public Health at reduced rates under the department’s federal contract. This financing system has been in place for the last three years, and in 2013 it saved the state nearly $50 million. The law makes the financing mechanism permanent, ensuring that no state funds would be used to finance the vaccine program.

The Massachusetts Immunization Registry will act as a statewide repository of all immunizations, one that can interact with electronic health records. It generates savings by reducing waste associated with over-immunization and allows for the tracking of the approximately 3.5 million doses of vaccine distributed annually by the Department of Public Health.  It will also help providers in keeping immunizations up to date by identifying those who are not vaccinated.  Massachusetts had been one of only three states in the country without a registry due to lack of funding.

This new law also comes at an opportune time.

Back in September in this space, I noted some key reasons why physicians should renew our efforts in advocating immunization for our patients.  I wrote that childhood diseases we thought were under control are reappearing with disturbing frequency; that more medical and philosophical exemptions to childhood vaccines are being allowed; and that the medical-conspiracy theorists are still at it, pushing misguided notions about ill effects of vaccines.  These conditions still exist.

In that same post, I also quoted Dr. Thomas R. Frieden, director of the U. S. Centers for Disease Control, who has said that “the doctor is the single most influential factor that determines whether kids get vaccinated.” That also remains true, and is worthy of repeating.

This new law will help physicians in their advocacy for vaccines and puts the Commonwealth in the position of maintaining its long-time leadership in childhood immunization, with high vaccination rates and low rates of vaccine-preventable diseases.

So despite the lack of headlines, despite its quiet passage, the Massachusetts Childhood Vaccine Program is great news for physicians and especially our young patients. It’s also a victory for public health in the Commonwealth.

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

The President’s Podium: Primary Care Competition

Posted in Accountable Care Organizations, Health, Health Policy, Health Reform, medical homes, Primary Care, Retail Clinics on October 15th, 2013 by MMS Communications – 1 Comment

by Ronald Dunlap, M.D., President, Massachusetts Medical Society DSC_0003 Dunlap 4x6 color 300 ppi_edited

The shortage of primary care physicians, besides creating longer wait times for both new and existing patients, is also changing how care is being delivered.

National pharmacy chains are seeking bigger roles in patient care, like managing chronic diseases, and they’re developing partnerships with medical groups large and small across the country.

Non-physician health professionals are also pressing for more opportunities. Nurse practitioners, for example, encouraged by a 2010 Institute of Medicine report, are engaged in advocacy and legislative efforts to establish independent practice, unburdened by physician supervision. Chapter 224 of Massachusetts General Laws, passed last year, included a new definition of primary care and expanded authority for NPs to sign documents once limited to physicians. This has given some NPs the impetus to set up independent practice.

What effects will these efforts have on primary care? Let’s take a closer look.

Retail clinics:  How often and for what purposes patients will visit retail clinics remain open questions, as these clinics are just now expanding their services from basic offerings to more complex endeavors such as lab services and managing chronic diseases. Unlike many other states, Massachusetts health officials have established a long list of regulations that these limited service clinics must follow.  However, Chapter 224 also requires the Department of Public Health to promote these clinics to the full extent of the scope of practice of NPs (who generally run these operations), but not to classify the clinics as primary care providers.

Research shows that patients like the convenience of retail clinics, particularly when they have difficulty getting to their primary care provider. Given the limited resources and no onsite physicians, most patients may not regard them, at least for now, as a place for primary care. As they add more sites, services, alliances, and advertising, however, they are likely to play a bigger role in health care – a prediction already being made by health care analysts.

Nurse practitioners: NPs play a vital role in health care. They always have, and they will play an even larger role as the team approach to care becomes more prevalent with medical homes and accountable care organizations.

The idea, however, that independent practice by NPs can fill the physician gap falls short. For one, a nursing shortage exists alongside the physician shortage, and nurses, like physicians, are an aging part of the healthcare workforce, with more than half of nurses approaching retirement.  The difficulty in recruiting nursing school faculty to teach a new generation adds to the problem.

Independent practice by NPs isn’t likely to increase the number of primary care providers; at best it might redistribute some to underserved areas. Most now work in urban areas, as physicians do, and most hospitals will not allow NPs on staff without physician supervision.

Further, with an emphasis on cost containment, replacing high-salaried providers (physicians) with lower ones (NPs) with less training will likely not result in savings. We have seen that less-experienced providers tend to order more tests and procedures, raising costs. Cost control will result best from the team approach of coordinating care and avoiding unnecessary referrals, testing, and procedures.

Finally, as independent or solo practice by physicians is becoming less and less viable with the growth of medical homes and accountable care organizations, the same is likely to happen with nurse practitioners.

While retail clinics and independent practices may have their place, continuity and coordination of care is much preferred over fragmented care from multiple providers. I believe the basis of good health care remains within the physician-patient relationship, supported by nurse practitioners, physician assistants, and other allied health professionals in a team approach. Patients will benefit most from this kind of an approach.

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

 

 

The President’s Podium: A Vote for Vaccines

Posted in Health, Medicine, patient safety, Primary Care, Public Health on September 4th, 2013 by MMS Communications – 1 Comment

If we need any reason to remind our patients about the value of vaccines, all we need do is look around our country and the world. Diseases once thought to be under control, even eradicated, are reappearing with disturbing frequency.

Measles and mumps outbreaks have occurred in Canada, Europe, and the Middle East. Polio has shown a fierce stubbornness, resurfacing in Somalia after six years. The disease has reached Israel, which is re-vaccinating one million children, from Pakistan, one of three countries, along with Nigeria and Afghanistan, where it remains endemic.

Those counties may be far away, but distance no longer offers the protection it once did.  A measles outbreak in Brooklyn earlier this year, brought back by an overseas traveler, is a stark reminder that an outbreak – or epidemic – can be just one plane ride away.

In the U.S., outbreaks have occurred coast to coast. According to the Centers for Disease Control, 2012 was the worst year in six decades for whooping cough with nearly 42,000 cases. The number of measles cases in the U.S., recently highlighted by an outbreak centered in a Texas church whose ministers reportedly questioned the value of vaccines, is on track this year to be one of the highest in 17 years. Mumps is returning as well, as evidenced by more than 100 cases in Virginia.

While immunization rates may be high for children, too many people appear to be losing sight of the importance of vaccines. More states (though our record in Massachusetts has been good) are granting medical and philosophical exemptions from childhood vaccinations, and the medical-conspiracy theorists are still at it – and even given potential platforms to air their misguided notions. ABC Television’s appointment of an outspoken childhood vaccine critic as a co-host of a widely-watched morning show, for example, has rightly caused outrage. It prompted a Boston Globe editorial, saying “the network shouldn’t let her use the show as a platform for her theories. Giving them even a moment’s notice would be a disservice to the public.”

The paper recognized an unfortunate truism: despite mountains of evidence on the safety of vaccines, scare tactics can still work with some people.

The irony – and frustration – of all this is that as more diseases become drug-resistant,  as new ones like MERS emerge, we continue to fight the old ones we can prevent.

The focus on vaccines must also encompass more than children. The vaccine for HPV, the most commonly sexually transmitted infection, has yet to gain widespread acceptance, and more than 50,000 adults die each year from vaccine-preventable diseases and their complications.

CDC Director Dr. Thomas R. Frieden, in urging the medical community to promote vaccinations, said recently that “The doctor is the single most influential factor that determines whether kids get vaccinated.”  It’s true for adults, too.

The message is clear: As with so many other areas in health care, physicians can make the biggest difference, one patient at a time.

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