Health Reform

MMS Forum Spotlights the Past, Present and Future of Health Reform

Posted in Accountable Care Organizations, Affordable Care Act, Health Reform, Payment Reform on October 30th, 2013 by MMS – 1 Comment
David Gergen

David Gergen

On the same day that President Obama spoke at Faneuil Hall to defend and promote the Affordable Care Act, the Massachusetts Medical Society’s 14th annual forum on the State of the State’s Health Care focused on the consequences and future of state and federal health reform.

Calling the ACA “both a triumph and a tragedy,” veteran White House advisor David Gergen said the political firestorm currently surrounding ACA implementation – reports of consumers furious that their private insurance policies face cancellation – has seriously jeopardized the future of President Obama’s signature legislation.

Gergen, currently director of the Center for Public Leadership at Harvard’s Kennedy School of Government, recommended a major public information campaign and more transparency from President Obama to rally public support for the beleaguered law.

Stuart Altman

Stuart Altman

Stuart Altman,  chair of the Massachusetts Health Policy Commission, spoke about the need for states to become more aggressive about reining in total health care spending – not  just  the amount public money spent to care for low-income or elderly patients.

Because health care costs are disproportionately pushed onto the privately insured, the long-running cost-shifting model is unsustainable.  “It is simply impossible for private insurance to make up for shortfalls in Medicare and Medicaid rates,” said Altman, a Brandeis professor who currently chairs the state’s Health Policy Commission.

He predicted a noticeable decline in medical care nationwide if costs are not more quickly brought under control and tightly connected to quality and outcome data. “Not a `lights-out,’ but more like a `lights flickering,’” he said.

Altman, a supporter of physician-led ACOs and bundled payment systems in Massachusetts, said the state’s new innovated approaches strive to avoid the “mistakes” of 1990s-era managed care systems, such as micromanaging doctors, dumping too much financial risk on providers, and forcing unwilling consumers to join plans.

Control of post-acute care spending and an effective primary care system will be keys to the future success of Massachusetts ACOs, Altman said.

John Noseworthy, MD

John Noseworthy, MD

Mayo Clinic CEO John Noseworthy, MD, spoke about his system’s culture of teamwork and patient-centered care.  He said more work is needed in most other health care systems nationwide to reduce fragmented and uneven care – factors that drive up the costs of care dramatically.

The Mayo system struggles with downward pressure on Medicare reimbursement rates, and Dr. Noseworthy said he expected the ACA would likely cut them an additional 15 to 25 percent.

While Mayo has six campuses nationwide, Dr. Noseworthy said his system’s survival lies not in acquisitions or consolidation, but in scaling its practice knowledge and experience to affiliates at independent practices and hospitals.  “We hope that our network can be an integrator for groups without the culture of an integrated practice,” he said.

The program also featured a panel of Massachusetts health care executives: Tufts Health Plan CEO James Roosevelt Jr., Boston Medical Center CEO Kate Walsh, and Stuart A. Rosenberg, MD, CEO of the Harvard Medical Faculty Physicians at BIDMC.

Dr. Rosenberg said he felt one of the most pressing problems was a failure to use IT to transform health care and help patients manage chronic health issues in their own homes.

Roosevelt urged more collaboration between providers and payers to control costs, and said the state must be vigilant in monitoring provider consolidation to ensure better care for patients is the result.

In her comments, Walsh focused on BMC’s dramatic financial turnaround in the wake of major state funding cuts.

But, Walsh warned, the state must stay vigilant in monitoring the needs of its poorest citizens “or access will be slaughtered on the altar of costs.”

—     Erica Noonan

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.

 

 

September Physician Focus: The Physician-Patient Relationship

Posted in Health, Health Reform, medical homes, Medicine, Physician Focus, Primary Care on August 30th, 2013 by MMS Communications – Comments Off on September Physician Focus: The Physician-Patient Relationship

Since the days of Hippocrates, the physician-patient relationship has been regarded as the foundation of good health care, thus making the selection of a physician one of the most important medical decisions a patient will make.

The September episode of Physician Focus provides an in-depth discussion of this key element of health care with two experienced primary care physicians.

Special guest for this program is MMS Vice President Dennis M. Dimitri, M.D., a board-certified family physician in Worcester, Mass. with more than three decades of primary care experience.

Dr. Dimitri, (photo, seated) Clinical Associate Professor and Vice Chair of the Department of Family Medicine and Community Health at UMass Memorial Medical Center and UMass Medical School in Worcester, joins fellow family physician and program host Mavis Jaworski, M.D. for the conversation.

Focusing on primary care, the physicians examine a range of topics, including what factors patients should consider when seeking a physician, the elements that make up a good physician-patient relationship, the barriers that might negatively affect the relationship, what patients and physicians might do if the relationship doesn’t seem to be working, and the potential impact on the relationship of new models of care such as the patient-centered medical home and accountable care organizations.

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

The President’s Podium: Unhappy Doctors?

Posted in Health Reform, Leadership, Medicine on August 12th, 2013 by MMS Communications – 1 Comment

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

The headline shouted the news – 60% of Docs Wouldn’t Recommend Their Profession as a Career – recounting the sentiments of a nationwide survey of nearly 3,500 physicians. And while we may parse the responses – Is it a generational thing? Does specialty matter? – it’s likely most physicians aren’t surprised at the result. Changes to our profession have been fast and extensive in recent years, and we’re constantly adjusting to new demands.

When six out of ten doctors, however, suggest they’re unhappy, it prompts some key questions. What might patients think of this? Are discontented doctors affecting the physician-patient relationship? Or are survey respondents just blowing off steam out of frustration?  I think that it’s an important issue. Here’s my take on the reasons behind the survey results:

Mounting administrative and mandated requirements. Prior authorizations, certifications, complex billing, and the myriad of administrative tasks before us all steal time from the thing we most love to do: engagement in patient care. Ever-expanding oversight (though some, we’ll agree, is good and necessary) through more and more rules and mandates from insurers, legislators, and regulators, some duplicating the others, steal more time, and chip away at the control we have over how we practice medicine.

The imposition of information technology. Advocates say IT will lead to better quality care, but for many physicians, it’s been more of a disruption than an improvement to medical practice. Big investments of money and time, without appreciable return, along with lack of interoperability among systems, have soured many on computers, despite financial incentives. Computers have provided some benefits and may yet prove to improve health care, but the evidence so far is limited, and the transition is not complete.

The cost of educating physicians. Many young doctors avoid primary care or public health positions in favor of higher-paying specialties that may offer a more flexible lifestyle. It’s easy to understand why, when they’re coming out of medical school with hundreds of thousands of dollars in debt. The extraordinary cost and years of training are raising questions about the return on their investment of time and money.

Other issues weigh on our perspective. These include declining and changing reimbursements, the specter of liability, the uncertainty of reform, and imperfect rating systems from a host of sources telling us how well (or not) we practice medicine.

These are legitimate concerns. I suggest, however, that our discontent is not with the practice of medicine, but rather with the business of medicine – a fact borne out by the survey that prompted this post. I suspect, as those who conducted the survey do, that the disenchantment was prompted in part by colleagues letting off steam.

As my fellow MMS members and I work to fix what’s wrong, I remind myself that “physician” remains at the top of every poll ever taken of most admired professions and that, in the words of Dr. William Osler, we are distinguished from all other vocations by our unique ability to do good. I hope my patients feel the same way.

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

 

 

April Physician Focus: Checkups and Screenings: What Do You Need?

Posted in Health, Health Policy, Health Reform, medical homes, Medicine, Physician Focus, Primary Care on April 1st, 2013 by MMS Communications – 1 Comment

The annual physical exam and other periodic screenings have for years been considered key elements to sound medical health, offering prevention against disease and illness. Yet recent studies have called into question the value of these exams, saying such testing has had no effect on reducing disease or death and in some cases causes harm.

The April episode of Physician Focus, Checkups and Screenings: What do you need?, offers an in-depth discussion of this issue with Michael Barry, M.D., president of the Informed Medical Decisions Foundation in Boston and medical director of the John D. Stoeckle Center for Primary Care Innovation at Massachusetts General Hospital. Hosting the show is primary care physician Mavis Jaworski, M.D.

Among the topics of conversation are the pros and cons of medical tests and treatments, how to decide which ones to have, why patients should have a greater voice in their health care decisions, and the concept of shared decision-making – physicians and patients working together so that, in Dr. Barry’s words, “good medical decisions are made with the full participation of an informed patient.”

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

 

Medical Liability Reform Begins in Massachusetts

Posted in Defensive medicine, Health Reform, Malpractice, medical liability reform, professional liability reform, Uncategorized on February 14th, 2013 by MMS Communications – Comments Off on Medical Liability Reform Begins in Massachusetts

With a research initiative begun three years ago that created a roadmap to reform, medical liability reform has now begun to unfold in Massachusetts.

The Massachusetts Alliance for Communication and Resolution following Medical Injury (MACRMI) this week announced the launch of its website detailing information on the reform efforts for Massachusetts patients and providers at www.macrmi.info.

MACRMI was formed as the result of the initiative begun in 2010 and led by Beth Israel Deaconess Medical Center and the Massachusetts Medical Society. Participants and supporters also include Baystate Health, Massachusetts Hospital Association, Massachusetts Coalition for the Prevention of Medical Errors, Medically Induced Trauma Support Services, as well as health insurers, provider organizations, and patient advocacy groups.

MACRMI has now started to implement the roadmap to reform, through a Communication, Apology, and Resolution (CARe) program (also known as disclosure, apology and offer, or DA&O), with pilot programs underway in six hospitals.

The six hospitals participating in the pilot initiative include three from the BIDMC health system (Beth Israel Deaconess Medical Center in Boston, Beth Israel Deaconess Hospital-Needham, and Beth Israel Deaconess Hospital-Milton); and three from Baystate Health system in Springfield (Baystate Medical Center in Springfield, Baystate Franklin Medical Center in Greenfield, and Baystate Mary Lane Hospital in Ware).

The research initiative by BIDMC and MMS was funded by a grant from the Federal Agency for Health Care Research and Quality as part of the President’s Patient Safety and Medical Liability Program.

A key step in the process was an unprecedented agreement on legislative language among the Massachusetts Medical Society, Massachusetts Bar Association, and Massachusetts Academy of Trial Lawyers. That agreement led to approval of the provisions enabling reform by the legislature and Governor and their subsequent inclusion into the payment reform bill that Governor Patrick signed last August. Among the provisions are a six-month, pre-litigation resolution period, sharing of all pertinent medical records, appropriate apology protections for providers, and full disclosure to patients.

Passage of the law made Massachusetts the first in the nation to have comprehensive legislation that will provide for the conduct of such a program in different practice environments with different insurance arrangements.

 

MMS Ethics Forum: Cost-Conscious Medicine

Posted in Ethics Forum, Health Policy, Health Reform, Interim Meeting 2012, Medicine on November 30th, 2012 by MMS Communications – 1 Comment

The overriding refrain in medical care over the last several years has been persistent if nothing else:  “the continuing cost of medical care is unsustainable.”  The subsequent calls for “cost-conscious medicine” have been ringing louder and more frequently.  The trend is inevitable, as governments at all levels, businesses of all sizes, and individuals who buy coverage struggle with strained budgets and rising costs.

The efforts for cost control in the Commonwealth culminated this year with Chapter 224, the cost-containment law passed earlier this year by the legislature.

So what might be the impact on physicians? How should physicians react? And what could it mean for patient care?

Some answers came from the 2012 Interim Meeting’s Ethics Forum, Serving Two Masters – What Practicing Cost-Conscious Medicine Means for Patient Care and the Public Trust.

Presenters included James E. Sabin, M.D., Clinical Professor in the Departments of Population Medicine and Psychiatry at Harvard Medical School and Director of the Harvard Pilgrim Health Care Ethics Program, and Martin Samuels, M.D., Professor of Neurology at Harvard Medical School and Neurologist-in-Chief and Chairman of the Department of Neurology at Brigham and Women’s Hospital and Co-Chair of Partners Neurology.

Over nearly two hours, the physicians offered their perspectives on the issue and the direction that physicians might take in today’s practice environment of ever-increasing fiscal constraints. Some excerpts from their presentations:

Dr. Sabin – “Implementing cost-conscious medicine will take time and will not be easy…the biggest impediment is more emotional than intellectual…We must involve patients and the public in our deliberations and policy-making…They will only trust the concept of cost-conscious medicine if they believe the quality of care is preserved and the savings will be used for good purpose.Physicians are the crucial players in this endeavor, we can be spoilers or leaders….It is our responsibility to make it work.”

Dr. Samuels – “The important question is which master do we serve? … Simultaneously considering the interests of society and the individual patient represents an irresolvable conflict of interest… Overutilization is expensive and dangerous….Errors are unavoidable, despite our best efforts, and without errors, we have no progress…Believe in the concept that physicians are required to do everything that they believe may benefit each patient, without regard to costs or the societal considerations…because the best individual care is cost effective.”


 

Health Care Leaders Address Elections, Economy, and “Value Medicine”

Posted in Health Policy, Health Reform, State of the State 2012 on October 18th, 2012 by Erica Noonan – Comments Off on Health Care Leaders Address Elections, Economy, and “Value Medicine”

About 10 years ago, Craig E. Samitt, M.D., the president and CEO of Dean Clinic in Madison, Wisc., made a decision.

Instead of focusing on “heads in beds” like so many health systems, his system would focus on what he now terms as “Value Medicine.”

“Let the rest of the industry focus on volume. We’re focusing on value,” Dr. Samitt recounted on Thursday during his address at the State of the State’s Health Care Forum, hosted by the Massachusetts Medical Society.

The leadership forum, now in its 13th year, also featured remarks by Massachusetts Governor Deval Patrick, Harvard School of Public Health Associate Dean Robert J. Blendon, and economist Robert J. Shapiro, who served as Under Secretary of Commerce for Economic Affairs during the Clinton Administration.

He described the hard-won lessons learned by his physician-owned and governed health system.  Namely,  ACOs must be a team of equals, with hospitals, physicians, and insurers all learning to partner, not compete with each other.

“Everyone has to integrate around value. All health care systems that succeed in the future will focus on teamwork,” Dr. Samitt said.

One of the most important changes was Dean’s investment in primary care. Instead of insisting that Dean PCPs see a huge volume of patients, said Dr. Samitt, “we turned the treadmill off” to instead focus on care coordination.

The system has also looked for ways to serve patients virtually and is making data on its physicians – including metrics on patient satisfaction – unblinded so that Dean’s doctors can see how they compare to their peers.  Soon those metrics will be tied to financial incentives, Dr. Samitt said.

In a set of remarks titled, “The Implications of the 2012 Elections for U.S. Health Reform,” Blendon spoke about a deeply divided national electorate, where health care currently ranks second in voter concerns.  The country is almost evenly split on federal health reform, but 52 percent want some, or all, of the ACA repealed.

Shapiro gave the forum’s final talk, titled “Healthcare and its Impact on the Economy.”

He discussed how rapid increases in health costs have contributed to slowing U.S. job and income growth, compared to European nations and Japan, where government cost controls are in place.  He predicted that if unchecked, U.S. health care costs could consume an estimated 30 percent of the average family’s income.

– Erica Noonan

Gov. Patrick Speaks on State of Massachusetts Health Care at MMS Forum

Posted in Health Policy, Health Reform, State of the State 2012 on October 18th, 2012 by Erica Noonan – Comments Off on Gov. Patrick Speaks on State of Massachusetts Health Care at MMS Forum

Massachusetts Governor Deval Patrick addressed the state’s largest doctor’s advocacy group on Thursday about the status of the health care and payment reform movements and the challenges that still remain.

Currently, the governor said, 98.2 percent of Massachusetts adults and 99.8 percent of children have insurance coverage. Universal health care has most benefited minority, women, and low-income residents.

Mortality rates for testicular cancer in Hispanic men and cervical cancers in low-income women have seen double-digit decreases because of improved screening services and access to care now available under state law.  An estimated 150,000 Massachusetts residents have stopped smoking due to expanded access to smoking-cessation programs, the governor said.

“We started with the belief that health is a public good…and that this is an expression of the kind of Commonwealth we want to live in,” said Gov. Patrick, the lead speaker at the State of the State’s Health Care forum hosted by the Massachusetts Medical Society.

The leadership forum, now in its 13th year, also featured introductions by Mass. Health and Human Services Secretary JudyAnn Bigby, MD, and remarks by Harvard School of Public Health  Associate Dean  Robert J. Blendon,  ScD, Dean Clinic President and CEO Craig Samitt, MD, MBA, and Robert J. Shapiro, PhD, an economist and  former U.S. Under Secretary of Commerce for Economic Affairs.

A separate and ongoing challenge in the state’s health care reform process is insuring that premiums and heath care spending remain under control.  Otherwise, they remain a significant obstacle to economic recovery.  Small business owners need to be certain they can afford to take on new employees.

“Eighty-five percent of businesses in the Commonwealth are small businesses. If they don’t start hiring, we don’t get a recovery,” Gov. Patrick said.

The payment reform legislation signed into law this summer  – which ties health care costs to state economic growth and includes medical malpractice reforms – is the next step towards a system that offers incentives for good care, not “more care,” the governor said.

After his remarks, the governor took questions from the physicians in the audience.  He addressed the state’s growing physician shortage and difficulty in the recruitment and retention of primary care physicians.    A promising debt-forgiveness program  for medical school graduates  that added dozens of new PCPs to the state had to be scuttled during budget cutbacks in recent years, he said.

The governor also urged physicians to become involved in new advisory commissions to help guide payment reform, and advised hospital administrators to continue their work in eliminating systemic cost inefficiencies.

— Erica Noonan

Video: Governor Patrick’s Remarks