Health Policy

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 ,, and

The President’s Podium: Physician, Inc.

Posted in Health Policy, Health Reform, Leadership, Payment Reform, Regulation on March 18th, 2014 by MMS Communications – Comments Off on The President’s Podium: Physician, Inc.

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

In my first post on this site last August, I called attention to a survey of DSC_0003 Dunlap 4x6 color 300 ppi_editednearly 3,500 physicians that found that 60 percent of physicians would not recommend their profession as a career.

I suggested that the finding was not surprising, as the high level of discontent within our profession is due mostly to the growing business and administrative requirements of medicine that we must meet and maintain. As we began our medical careers, few of us thought we would become “providers” in the health care “industry.”

The March edition of our member newsletter, Vital Signs, recognizes this reality with the theme of The Business of Being a Physician.  My President’s Message in that issue said “we cannot pretend that we can divorce ourselves from the financial realities battering the health care industry.”  Like it or not, the establishment of business principles in the profession of medicine long ago stopped being a trend; it has been a reality to an increasing extent, and is now widespread.

The business and financial aspects of medicine weigh on all of us. They threaten the viability of many practices and push physicians to make hard choices about their profession and careers.  They intrude into the physician-patient relationship, steal time from engaging our patients, and erode the control we should have over how we practice medicine and how we care for our patients.

The legislative, regulatory, and commercial mandates and requirements continue to increase. Some of these changes are positive; some not so much so. Collectively, however, they present enormous challenges.

At the Federal level, the Affordable Care Act has set regulations on such areas as quality reporting, physician ownership and referrals, medical homes, accountable care organizations and payment practices.  The presence of the Independent Payment Advisory Board, despite its inactivity, still looms, and the explosion of billing codes, known as the ICD-10, is scheduled to take effect later this year.

At the state level, legislative efforts such as Chapter 224 have added more requirements: insurance regulations governing such newly-named entities as “Risk-Bearing Provider Organizations,” proficiency with electronic medical records, and price transparency, just to name a few.  Regulations and requirements from insurers and regulators further add to our administrative load.

We are being inundated with compliance measures and calls for metrics and analytics and other databases, even when many practices are ill-equipped to provide such information given inadequate or nonexistent health information technology systems.

The Medical Society continues to speak out on these issues. In testimony before the Massachusetts Health Policy Commission in February, I pointed out that the rising number of requirements asked of physicians takes time away from patient care, adds to administrative demands, and raises the costs of practicing medicine.  I further said such requirements will drive small to mid-sized practices to merge or align with larger entities that have the ability to meet such requirements and that this could lead to further consolidations and higher costs in the health care market –a phenomenon already well underway in the Commonwealth.

On the national level, rising physician frustration with the direction of medicine is leading more of our colleagues into the political arena. A New York Times report of March 8  noted that “a heightened political awareness and a healthy self-regard that they could do a better job, are drawing a surprising large number [of physicians] to the power of elective office.”

Such political activism by physicians is rare at the state level.  Whether more physicians in national office, while a hopeful sign, will affect change remains to be seen. But it is likely to alter one critical dynamic: bringing added weight to the voice of physicians in the conversation about health care.  That is a key development.

It is imperative that those who propose changes to the practice of medicine recognize and understand how the consequences of those changes – intended and unintended – will affect the practice of medicine.  Who better to tell them than those of us on the front lines of patient care?  We must accept that we’re now part of an “industry” and that the “business of medicine” is here to stay due to cost constraints. It is necessary however, for physicians to have an unmistakable and conspicuous voice in how that business operates.

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

Why Does Massachusetts Health Care Cost So Much? Here’s What the Health Policy Commission Thinks

Posted in Health Policy, Health Reform on December 20th, 2013 by MMS – 1 Comment

It was no surprise when the Health Policy Commission reported this week that Massachusetts health care spending is much higher than the national average.

But physicians, health care leaders and others should take note of what commission believes are the causes of our high costs. Just as in medicine, diagnosis informs treatment.

Without commentary or endorsement, and as concisely as we can, here’s a summary of what the commission said in its preliminary report

  • Massachusetts is No. 1 in the country for personal health care expenditures:
    • Massachusetts: $9,278 per person
    • U.S.: $6,815
    • That’s a difference of 36%
    • If you adjust the data for our older population, broad access to care, and higher overhead costs (wages, rent, supplies, etc.) the difference is still 20%.
  • For private health insurance patients:
    • Hospital spending is 42% higher than the U.S. average
    • Long term care spending is 31% higher
    • Professional services spending is 24% higher (physician, clinical, dental and other services)
    • Spending on drugs and medical durables is about equal
  • For Medicare patients, spending is 9% higher than the U.S. average
    • Hospital care spending is 90% higher than the U.S. average
    • Long term care spending is 53% higher
    • Professional services spending is 35% lower
  • For Medicaid patients, spending is 21% higher than the U.S. average
    • Factors explaining the difference include the health status of enrollees, breadth of benefits, and higher reimbursement rates than the national average
    • Hospital care spending is 31% higher than the U.S. average
    • Long term care spending is 73% higher
    • Professional services spending is 5% higher
  • Why do we spend more? Higher utilization and higher unit prices
  • Hospital utilization
    • Inpatient admissions: 10% higher
    • Average length of stay: 7% lower
  • Outpatient  utilization
    • Patient visits, excluding emergencies: 72% higher
    • Outpatient surgeries: 27% higher
  • Why are prices higher? Higher fee schedules, and more care is delivered in higher-priced settings
    • Using claims data, fees paid by commercial payers, Medicare and Medicaid are higher than the national average
    • Portion of Mass. discharges from major teaching hospitals: 41% 
    • Portion of U.S. discharges from major teaching hospitals: 16%
  • Massachusetts outperforms national average on many quality benchmarks, such as
    • Childhood immunization rate
    • Low birth weight
    • Cholesterol management for patients with CV conditions
    • Controlling high blood pressure
    • Patient safety

Want more of the numbers? Here’s the commission’s preliminary report (pdf, 37 pages).

Its final report is due in January.

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.  


Interim Meeting Ethics Forum: Ethics in ACOs

Posted in Accountable Care Organizations, Ethics Forum, Global Payments, Health Policy, Health Reform, Interim Meeting 2013, Payment Reform on December 6th, 2013 by MMS Communications – 2 Comments
Susan Dorr Goold, MD

Susan Dorr Goold, MD

The accountable care organization (ACO), loosely defined as a group of providers that accepts responsibility for the total care of a patient and is accountable for high quality care and the cost of care, is a rapidly growing concept whose aim is to reduce the rising costs of care and improve quality.

While the emphasis on ACOs has focused on cost and outcomes, less attention has been paid to the ethical considerations of delivering care within such a structure.  As the ACO continues to evolve, what are the ethical issues that physicians might face as they practice medicine?  Do healthcare institutions, as well as individual providers, face ethical issues as organizations? And how might ethical considerations influence payment structures?

These are some of the issues discussed at the Ethics Forum, held on the first day of the 2013 MMS Interim Meeting of the House of Delegates.

Presenting were Susan Dorr Goold, MD, professor at the University of Michigan and Chair of the American Medical Association’s Council on Ethical and Judicial Affairs, and Philip F. Gaziano, MD, chairman and CEO of Accountable Care Associates, a Springfield-Mass. based healthcare management company.

In two presentations over two hours, delegates heard perspectives on the practical and ethical challenges in making a transition to an ACO, who providers are accountable to and for what within an ACO while maintaining their first loyalty to the patient, conflicts of interest that may arise, and ways to protect patient autonomy while practicing in an ACO.

Some highlights from the presenters:

Dr. Goold, in a presentation entitled Strengthening Patient-Physician Trust in Accountable Care Organization, examined the elements of personal and organizational accountability that lead to strong physician-patient relationships.  Professionals, organizations and patients all have a responsibility in strengthening trust, she said: professionals with a duty to “seek trust from patients” based on openness and honesty, patients by being truthful and to trust wisely, and organizations as “moral characters” in modern society.

Dr. Gould also outlined the challenges to trust in physicians (patient expectations, requests, and demands) and health care institutions such as hospitals and payers (safety of personal information, treatment decisions, fair and prudent use of resources). She concluded with the notion that physicians and healthcare institutions have “moral responsibilities in health care” to include advocacy, competence, fairness, and honesty, among others.

Dr. Gaziano’s Ethical Considerations in Accountable Care Organizations focused on the payment considerations with ACOs, comparing fee-for-service to global payments (payments based on Relative Value Units) to Quality Value Units, a new designation created by his firm that provides the advantages of tracking and reporting in real time, predictive value, and the tracking of quality and budgets. He also addressed physician concerns: why ACOs are different from earlier cost-saving attempts like HMOs and opportunities within the new system of ACOs such as payments and managing budgets.

The presentations of both physicians are available on the MMS website 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.

The President’s Podium: A Tough Start, but Worth Pursuing

Posted in Health, Health Policy, Health Reform on October 23rd, 2013 by MMS Communications – 2 Comments

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

We’re only a few weeks into the rollout of the Affordable Care Act, and DSC_0003 Dunlap 4x6 color 300 ppi_editedby most accounts, it’s been a rocky start at best.  Technology failings, consumer frustration, changing deadlines and other problems are all painting a gloomy picture of what might lie ahead. Even some physicians are expressing reservations, unsure that they’re going to participate in the exchanges.

Figuring out where we might be six or twelve months or more from now is almost impossible.  A massive overhaul of the nation’s health care system affecting such a big part of the nation’s economy will take time to settle. Even one of the program’s most ardent advocates admits the law is not perfect and “virtually any section or provision of this law could have been better.”

So we shouldn’t be swayed by daily reports in the media, whose members always seek instant results and immediate judgments on success or failure. Pundits pro and con are jumping on the best and worst aspects of what’s happening right now, quick to justify their viewpoints.

Since the ACA was passed three years ago, the nation has sought answers from Massachusetts as the first state to enact universal coverage. Reporters from around the country have been asking any number of questions: How did it happen? How has it affected patients? Do physicians like it? Are insurers behind it? How did it affect  costs?

Massachusetts will thus be forever linked to national health reform, and we can take some pride in that.  A broad coalition of different interests came together in 2006 to make it happen in Massachusetts. Physicians, notably, overwhelmingly supported the Massachusetts effort, with 70% in favor and only 13% opposed, according to a Harvard poll in 2009. And when asked about the law’s future, even more – 75% – wanted the law to remain in place.

When the ACA was first proposed, the Massachusetts Medical Society stated its support, saying “we believe this legislation should go forward, to fulfill the promise of providing all Americans with health insurance coverage and to enact long overdue insurance reforms. This legislation builds upon the groundbreaking Massachusetts universal coverage law. [It] is a first step to meaningful health care reform and achieving universal coverage for all Americans.”

At the same time we said it was important “that Congress enact legislation that ensured that patients will have access to physicians as well as correcting other problems with this bill,” specifically noting that it was crucial that Congress pass a permanent change to the Medicare physician payment formula and that certain provisions in the ACA, such as the Independent Payment Advisory Board, should be corrected,  as they could “undermine the quality of health care.”

Those important issues remain, along with the question of cost control (at both the federal and state levels). Physicians are continuing to work on them, both nationally and locally.

The judgment here is that the ACA is landmark legislation that, properly conducted, can result in enormous good for our country and our patients. Federal officials, however, must quickly fix the faults now plaguing the system before frustration breeds contempt that will erode a program that could benefit so many.

Despite its current failings, the negative public attitudes, and its future challenges, the Affordable Care Act still holds the promise of better care and better health outcomes for millions of our citizens. Those are goals certainly worth pursuing.

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: 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.



How the Federal Shutdown Affects Health Care

Posted in Health Policy on October 1st, 2013 by MMS – Comments Off on How the Federal Shutdown Affects Health Care

Updated Oct. 10, 2013

The shutdown of most federal government services has had varied effects on federal care programs.


  • The Medicare program has experienced little disruption; claims are being paid.
  • No delays are currently expected regarding the scheduled transition of Part B billing to National Government Services on Oct. 25.
  • Other activities conducted by the Centers for Medicare and Medicaid Services (CMS), including health care fraud and abuse control, the Center for Medicare and Medicaid Innovation, and activities related to implementation of the Affordable Care Act, will continue.
  • States will continue to receive funding for Medicaid and the Children’s Health Insurance Program.
  • The National Institutes of Health will continue patient care for current patients and have minimal support for ongoing protocols.
  • The Food and Drug Administration will continue limited activities related to its user fee funded programs, as well as select vital activities.
  • The Indian Health Service will continue providing direct clinical health care services and referrals.

Among the activities that will not continue:

  • CMS will not continue discretionary funding for health care fraud and abuse strike force teams. Fewer recertification and initial surveys for Medicare and Medicaid providers will be completed.
  • FDA will be unable to support most of its food safety, nutrition, and cosmetics activities.
  • With limited exceptions, NIH will not admit new patients or initiate new protocols, nor will it take any actions on grant applications or awards.
  • The Centers for Disease Control and Prevention will be unable to support the annual seasonal influenza program.
  • The Health Resources and Services Administration will be unable to make payments under the Children’s Hospital GME Program and Vaccine Injury Compensation Claims.

About 52 percent of HHS employees have been furloughed, with grant-making and employee-intensive agencies (e.g., the Agency for Healthcare Research and Quality) experiencing the most severe impacts. Most staff will be retained in agencies that have a substantial direct service component, like the Indian Health Service.

The President’s Podium: Getting Closer to a Medicare Payment Fix

Posted in Health Policy, Medicare, Payment Reform on September 18th, 2013 by MMS Communications – Comments Off on The President’s Podium: Getting Closer to a Medicare Payment Fix

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

Mention “SGR” to physicians and you can almost see and feel the tension and level of frustration.

For nearly a dozen years, this Sustained Growth Rate formula has called for massive cuts in Medicare reimbursements to physicians.  For each of those years, Congress has stepped in at the eleventh hour to avoid the cuts and provide a modest increase. Yet, for all those years, physicians worried about the viability of their practices and their patients.  And patients, having read and heard media reports about the possibility of physicians abandoning Medicare because of potential cuts in payments, may have wondered if they would continue to have a doctor.

We’re now closer to a permanent fix than ever before. On the last day in July, the House Committee on Energy and Commerce reported the “Medicare Patient Access and Quality Improvement Act” by a unanimous vote of 51-0. That bill repeals the SGR and replaces it with annual updates and new quality incentive measures.  Adding to the hope of a fix is a report from the Congressional Budget Office that estimated the cost to eliminate the SGR formula at about half the price of repeal last year.

However, two additional committees, House Ways and Means and Senate Finance, are scheduled to produce their own versions of the legislation, which will likely be combined and then brought to a vote in both the House and Senate.

While the 51-0 vote and CBO report raise hope, the work is far from done. Many key issues remain to be resolved, among them the adequacy of the proposed increases, the complexity of the new quality reporting system, and provisions for small practices that will allow them to maintain their viability and keep their doors open for their patients.

The AMA, in an effort to keep the momentum going, has launched Fix a website with three distinct channels: one each for physicians, patients, and policymakers, allowing each a voice on the subject and the ability to participate in the discussion.

The Massachusetts Medical Society, with the participation of many of our district presidents who have written letters to the editor to newspapers and media outlets across the state, has encouraged our Senators and Congressional representatives to make these changes a priority for Congress and finally reach a reasonable “fix” for a problem that has long plagued physicians and patients alike.

A new and better payment formula and better quality measures will help to stabilize Medicare for years to come. It will ease the minds of Medicare and Tricare patients in knowing their doctors will be there for them.  We’ve never been closer to fixing a broken system. It is imperative that physicians and patients alike maintain the momentum by urging Congress to capture the opportunity before them.

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