Primary Care

A Day in the Life of a Physician: Part 3

Posted in A day in the life of a physician, Primary Care on August 20th, 2010 by MMS – Comments Off on A Day in the Life of a Physician: Part 3

By Robin Dasilva and Therese Fitzgerald

This is the third in a series of four posts about a day in the life of Barry Izenstein, MD, an endocrinologist and internal medicine physician who practices in Springfield and Holyoke, Mass. Read Part 1 and Part 2.

Why I Am a Physician


Dr. Barry Izenstein’s dedication and compassion for his patients illustrates his motivation for choosing to practice medicine.

“Medicine was a calling, I thought about going into medicine since high school. I was also influenced by my father, who was a physician, and I wanted to take care of sick patients,” he said. “During my medical training in the 1970s, it was popular to go into a sub-specialty. I wanted to practice internal medicine, but also wanted to be a consultant in endocrinology in order to bring something else to internal medicine. Internal medicine and endocrinology seemed to go hand-and-hand. “

Dr. Izenstein explains that there are important characteristics needed to pursue the specialties he has chosen.

“Internists and endocrinologists must first be good listeners. Patients may arrive with multiple symptoms and signs that the physician must be careful to pay close attention to. They must also have the ability to pull together various facts and diagnoses in order to devise a plan for their patients.  A person doesn’t come in with one condition or diagnosis. Therefore, the physician needs to act like the conductor of the symphony, and the orchestra is the human body.”

Around noon, Dr. Izenstein takes a time out to have lunch. But just because he’s taking a break from seeing a constant stream of patients to eat a salad doesn’t mean he’s not working. Lunchtime consists of checking e-mails and returning phone calls between bites of his salad. Some of the e-mails Dr. Izenstein answers pertain to his work as a governor of the American College of Physicians.

Although Massachusetts consistently ranks high compared to other states for the number of physicians per 1,000 population, Dr. Izenstein’s juggling act reminds us that many of the physicians working in Massachusetts are balancing work and other health care sectors including research, teaching and leadership positions, in addition to — or in lieu of — providing direct patient care.

During lunch, Dr. Izenstein shares his thoughts on the passage of health care reform in Massachusetts and how it has impacted his medical practice.  To summarize his opinions, he refers to an article he had written for a local medical journal outlining the three essential elements he believes are needed in the national health care debate: universal access; fix primary care; and reform the tort system.

Dr. Izenstein believes that no matter what changes occur under health care reform, “My relationship with my patients will never change.” He does hope that ongoing health reform efforts will allow internists to spend “more time, not less, with their patients in the exam room.”

The hospitalist movement has changed the lifestyles of physicians coming into practice. Internal medicine practice is totally different now with not having to care for patients in the hospital. In this new generation you work in a hospital or private practice, not both. This allows for more time to attend soccer games and improve a physician’s lifestyle. Lifestyle is no longer going to be an issue for internal medicine physicians. It is far easier than a cardiologist, for example, who must bear the brunt of working in the emergency room in the middle of the night., although, cardiologists are compensated nicely.

Dr. Izenstein’s salad is almost gone and he has just enough time before his next scheduled patient to run next door to Baystate Medical Center to check on a couple of his patients who have been admitted for inpatient care. Although Dr. Izenstein’s patients are cared for by hospitalists when they are inpatients, Dr. Izenstein takes time to visit with them. Although he is not reimbursed for these visits, he likes to let his patients know that he is still involved and that he is available if they or the hospital staff needs him. Dr. Izenstein’s patients appeared happy to see him, and their family members thanked him for taking the time to visit with him

In Part 4: Dedication from Physician and Staff

A Day in the Life of a Physician: Part 2

Posted in A day in the life of a physician, Primary Care on August 19th, 2010 by MMS – Comments Off on A Day in the Life of a Physician: Part 2

By Robin Dasilva and Therese Fitzgerald

This is the second in a series of four posts about a day in the life of Barry Izenstein, MD, an endocrinologist and internal medicine physician who practices in Springfield and Holyoke, Mass. Read Part 1 here.

The Challenges of Practicing Medicine in Massachusetts

Mid Morning

DSCN0688Dr. Izenstein’s next patient smiles warmly as he enters the examination room. He asks if Dr. Izenstein enjoyed the coffee he brought back for him from his homeland in Latin America. After asking the patient a number of health-related questions, they discuss the patient’s medications and a recent visit to a specialist. Although the patient has brought his medications with him, Dr. Izenstein does not have any information from the specialist’s office regarding his visit. Without this information, it is difficult for Dr. Izenstein to reconcile the patient’s chart and medications with those of the specialist’s office and has to obtain the necessary information verbally from the patient.

Dr. Izenstein is hoping that these types of issues no longer occur with the implementation of an electronic health record (EHR) system at the office, and his staff is cautiously optimistic about the transition. The staff hopes that the EHR system will make things easier for the practice in the long run. According to the practice manager, an EHR system would help cut out transcription costs to dictate charts. Transcription costs have increased with increased audits by insurance companies. However, the practice does have a system in place for prescribing electronically.

For now, Dr. Izenstein makes do with the information provided by the patient and continues his examination. Dr. Izenstein listens to the patient’s opposition to the surgery Dr. Izenstein has suggested. Together they discuss alternatives to the procedure and agree to continue postponing surgery until further discussion at the patient’s next appointment. The examination continues with Dr. Izenstein checking the diabetic patient’s blood pressure, listening to his heart and lungs, and examining his feet. Dr. Izenstein prescribes new medication for the patient based on their conversation and makes certain he is sending the electronic prescription to the correct pharmacy.

While Dr. Izenstein continues seeing patients, his practice manager discusses her thoughts about maintaining a practice in today’s environment.

“It is more difficult from a cost perspective to maintain a practice today than in past years,” he said. “This year, the practice’s revenue has been impacted largely by increases in premiums for our employees. The premium increases are much higher than in previous years. Also, insurance companies are placing more responsibility on the patient to pay up-front, i.e., increase in co-pays. Many patients cannot afford increased co-pays.

“Therefore, in many cases, the practice waives the co-pays for patients and the practice picks up the cost.  Patients are waiting longer to schedule appointments with physicians due to cost of co-pays.  Physicians have also seen an increase in patient calls. Patients would rather call than come in to see a physician and pay the co-pay.”

In Part 3: Why I Am a Physician

A Day in the Life of a Physician: Part 1

Posted in A day in the life of a physician, Primary Care on August 18th, 2010 by MMS – 1 Comment

By Robin Dasilva and Therese Fitzgerald

This is the first in a series of four posts about a day in the life of Barry Izenstein, MD, an endocrinologist and internal medicine physician who practices in Springfield and Holyoke, Mass.

A Specialty in Crisis

Early Morning

Barry Izenstein, MD, FACP, begins his busy day at 8:00 a.m. the way he has for the past 20 plus years: caring for veterans at the Soldiers’ Home in Holyoke. After consulting with the nursing staff on duty, he performs rounds greeting and examining his patients. Today he is concerned not only with the well-being of his patients, but also with their future care as the threatened closing of the home and its outpatient clinics weighs heavily on his mind.

“These patients have fought for their country and deserve to have their health needs met, “he said. “I worry that they will have great difficulty finding new primary care physicians and the stress they will experience with the transition to a new health care system.”

Dr. Izenstein does more than advocate and care for patients. He served as Governor of the Massachusetts Chapter of the American College of Physicians. In that role, he encourages internists in Massachusetts to provide input and take action on national and local political issues affecting internal medicine. He also hosts local scientific meetings and continuing medical education events, and encourages medical student members and associates to participate in local and national college activities. In addition, Dr. Izenstein educates and mentors young physicians in his role as assistant clinical professor of medicine at Tufts University School of Medicine.

(Note: Thanks to the efforts of Dr. Izenstein and others like him, funding for veterans’ services was restored and care continue to be provided to the veterans at the Soldiers’ Home.)

As a founding partner of Endocrine Associates of Western Massachusetts in Springfield, Dr. Izenstein reports to his practice at 9:00 a.m. for his first of 24 appointments of the day. His first patient has already had his weight checked by the medical assistant and is now waiting in the examination room.

The patient is happy to see Dr. Izenstein and eager to share photos of his new dog. After a short conversation about dogs, Dr. Izenstein begins the visit by examining the patient’s chart and asking him a number of health-related questions, including any changes to his health, medications he is currently taking, and how he is feeling overall.

The patient examination begins with a check of the patient’s blood pressure and pulse, tasks often performed by a medical assistant, but Dr. Izenstein likes to do it himself. As he continues with the examination, Dr. Izenstein talks to the patient about his overall health and well-being and makes suggestions for preventive measures he believes can lead to further improvement.

At the end of the patient’s visit, it becomes apparent that the primary care shortages documented over the past four years in the MMS Physician Workforce Study are all too real. The patient asks Dr. Izenstein if his niece can make a primary care appointment with Dr. Izenstein, but he says his panel is currently closed to new primary care patients.

Later, Dr. Izenstein explains that his biggest challenge as a physician is primary care.

“Caring for the whole patient and responding to all of their needs is a monumental task,” he said. “Likewise, in today’s environment, with the imbalance in paperwork and compensation for time and work, selling primary care to students is a difficult task. Indeed, perhaps that should be health reform’s number one goal.

“A bigger issue is that primary care is undervalued, underpaid. Studies have shown that a system with primary care as its main driver has better outcomes, better quality, and lower costs. Thus, with primary care soon to be in crisis, shouldn’t primary care be the first and foremost concern for the new health overhaul?  With tens of millions of newly insured citizens and only a handful of new primary care physicians.

In Part 2: The Challenges of Practicing Medicine in Massachusetts

Mass. Medical Home Project is About to Begin: Apply Now

Posted in medical homes, Primary Care on July 16th, 2010 by MMS – Comments Off on Mass. Medical Home Project is About to Begin: Apply Now

380892395_1046c983a0_bThe Commonwealth of Massachusetts is about to start a project that could transform the practice of primary care medicine, if it’s successful.

This week the state announced that it’s accepting applications for its three-year Patient Centered Medical Home Initiative. The project will test the proposition that medical homes can improve quality and efficiency, and perhaps even save the primary care practice.

The deadline to apply is August 12, 2010.

The program includes some financial support, lots of training, and the assistance of a facilitator to help practices as they go along.

Unfortunately, applying is not a simple process. The application is funneled through the state’s public procurement system, which automatically brings into play a lot of arcane state laws and regulations. The application itself is 39 pages long. That’s why the state is holding two webinars next week to help practices through the process.

But given its promise for making a difference in primary care medicine, we think it’s worth the effort to apply.

The MMS website has information on the application process and the webinars.

The state’s website has lots of good background information on the overall project.

Mass. Practice Environment Dips Again

Posted in Health Policy, Malpractice, Medicine, Primary Care on May 25th, 2010 by MMS Communications – Comments Off on Mass. Practice Environment Dips Again

MMSIndex_colorMake it 16 down years out of 18.  The MMS Physician Practice Environment, a statistical reading of nine measures affecting the practice climate for physicians in the state, took yet another dip in 2009 and hit a record low.

Four factors led the decline in 2009: professional liability rates, the increasing use of emergency rooms by patients, an aging physician population, and the increasing cost of maintaining a practice.

“A strong physician practice environment is essential to maintain a strong physician workforce,” said MMS President Alice Coombs, M.D., commenting on the analysis in a posting on WBUR’s Commonhealth website.  “And its importance should be self-evident: it has a direct influence on patient care. Yet this latest analysis brings us more sobering news.”

Of the measures leading the decline, Dr. Coombs said professional liability and emergency room use were the most troublesome. Professional liability has been the driving force behind the decline of the index for years, and Dr. Coombs said a “critical step forward to improving the practice environment would be to enact liability reform.”  The rise in emergency room use highlights a new and disturbing dimension of the index, as it points to the delivery of primary care taking place in emergency departments.

A picture of the state’s practice environment from year to year is valuable by itself. But the MMS analysis includes a index for the nation as a whole, providing a reference point to judge changes in the state.  And a comparison reveals stark differences between the state and the rest of the nation as the four factors leading the state’s decline increased at a rate substantially faster than the national rate. The conclusion: when it comes to providing a good practice environment for physicians, Massachusetts and the nation are headed in opposite directions. Since 2006, the Massachusetts Index has declined 1.5 percent, while the U.S. Index has advanced 1.2 percent.

“Reversing the decline in the physician practice environment will lead to a stronger, more viable health care delivery system,” Dr. Coombs wrote. “The current climate should be cause for concern. And action.”

Read Dr. Coomb’s post on WBUR’s Commonhealth

MHQP: Using Quality Measurement to Improve Patient-Centered Care

Posted in Health, Health Policy, Primary Care on February 11th, 2010 by MMS Communications – Comments Off on MHQP: Using Quality Measurement to Improve Patient-Centered Care

By Barbara Spivak, M.D., President, Mount Auburn Cambridge IPA, and Edward Westrick, M.D., Vice President, Medical Management, UMass Memorial Health Care

Pulseline_24595MEDWith the turmoil surrounding health care issues nationally, it can be easy to forget that, besides taking the lead on expanding access through insurance reform, Massachusetts has been a pioneer in forging consensus around how to measure and report quality data. In fact, this week marks the sixth year that Massachusetts Health Quality Partners (MHQP) has released a report on how medical groups across the state perform on multiple measures of clinical quality.

Once again there’s plenty of good news. Overall, primary care physicians at more than 150 of the state’s medical groups performed better than the national average on 28 of 29 adult and pediatric quality measures reported by MHQP, and above the national 90th percentile on 15 of them.

As Massachusetts turns its attention to addressing the cost and quality of care through delivery system reform, performance measurement promises to play an increasingly important role. Dr. Jack Evjy, MMS Senior Medical Advisor, in a posting on this blog, outlined three essential elements of “patient-centric” system reform: taking an evidence-based approach to care; addressing unnecessary variation, both for under-utilization and over-utilization; and insisting on coordination and collaboration. We couldn’t agree more. Within our own organizations, and as members of MHQP’s Physician Council, we have seen that credible quality data can help drive patient-centered improvements. Here are a few examples of how MHQP’s approach to performance reporting aligns with Dr. Evjy’s criteria for reform.

Focus on evidence-based care
MHQP develops their performance reports through a collaborative, evidence-based process based on national standards for clinical quality that are closely related to patients’ health and well-being. Since MHQP compiles HEDIS® data from the state’s five major health plans, their reports generally include enough patients to make the data credible and meaningful at the group level. What’s more, MHQP’s only agenda is quality improvement, and they work closely with all of the major stakeholders, including the Massachusetts Medical Society, to make sure their reports reflect that spirit.

Address unnecessary variation in both under-utilization and over-utilization
Even with high levels of performance overall, MHQP still finds that there are significant variations and opportunities for improvement across the state. For instance, one MHQP measure looks at the percent of patients, age 40 and older, who have had a spirometry test to confirm the diagnosis of COPD. The statewide average is 40 percent. While the rate for the best performing group was 64 percent, the lowest rate was only 17 percent, indicating a strong possibility of under-utilization for this simple test.

Similarly, wide variation exists in the over-utilization of imaging studies for adults with low back pain – the best performing group made appropriate use of imaging 97 percent of the time, compared with the lowest-scoring group, at just 52 percent. Improved performance in this measure not only results in safer, better-quality care, but helps reduce unnecessary medical spending.

Encourage coordination and collaboration
It is difficult, if not impossible, to make and sustain measurable improvements in clinical quality  without enhancing teamwork within physician groups. In its press release on their latest clinical quality report, MHQP touches on two examples of how groups have used their performance data to address a major opportunity for improving the treatment of patients with severe depression. In both cases, care coordination and collaboration were key elements of success.

Quality reporting is about to enter a new era as the expanded use of electronic medical records and meaningful use requirements may offer for more refined measures of clinical outcomes than traditional claims data, and MHQP will undoubtedly play an important coordinating role in that transition.  In the meantime, however, the collaborative work done thus far by MHQP has built a strong foundation for delivery system reform – one that is unmatched in most other states.

Dr. Ashare: Concussions don’t discriminate

Posted in Primary Care, Public Health on February 8th, 2010 by MMS Communications – Comments Off on Dr. Ashare: Concussions don’t discriminate

The National Football League’s decision to focus more attention on concussions, or mild traumatic brain injury, is a very good thing, says Alan B. Ashare, M.D., chair of the Medical Society’s Committee on Student Health and Sports Medicine.

But in a newspaper commentary, he argues “While football has brought notoriety to the issue, awareness must spread beyond the gridiron.”

Dr. Ashare, a physician at St. Elizabeth’s Medical Center who is also Chair of the Safety and Protective Equipment Committee for USA Hockey, says “Concussions don’t discriminate by age, gender or activity,” and that “The notions of “toughing it out” or “walking it off” are thankfully giving way to the common sense approach of deciding what’s best for the health of the athlete.”

He urges that parents, coaches, trainers and physicians learn more about concussion and recognize the risk of such injury in other sports and recreational and playground activities as well as football.

Dr. Ashare’s commentary has been published in The Berkshire Eagle in Pittsfield, The Standard-Times of New Bedford, and The MetroWest Daily News in Framingham and has been submitted to other daily papers across the state.

Read Concussion issues go beyond football

Dr. Izenstein: 3 Basics for Health Care Reform

Posted in Defensive medicine, Health Reform, Malpractice, Primary Care on November 2nd, 2009 by MMS Communications – Comments Off on Dr. Izenstein: 3 Basics for Health Care Reform
Dr. Barry Izenstein, Governor of the Massachusetts Chapter of the American College of Physicians, in a letter to the editor of the Springfield Republican published November 1, says “Let us not get caught up in silly, petty, unfounded arguments when it comes to health-care reform. Indeed, if the current bill fails, the result will be more uninsured patients and more families going bankrupt because of high health-care premiums and bills.” Dr. Izenstein lays out three objectives for health care reform: provide all american with access to affordable health insurance; create incentives to reverse a “growing and catatrophic shortage” of primary care physicians; and reform the medical liability system. 

Read Health Care Reform is Good for Patients
The Republican, Springfield, November 1, 2009

A Really Bad Idea

Posted in Health, Health Policy, Health Reform, Medicare, Primary Care on September 7th, 2009 by MMS – Comments Off on A Really Bad Idea

In a co-authored commentary in today's Boston Herald, MMS President Mario Motta, M.D. and Massachusetts Hospital Association Chair and Tufts Medical Center CEO Ellen Zane call attention to a proposal being considered by Congress that would dramatically alter Medicare payments and thus have a huge impact on health care in Massachusetts and 13 other states. The proposal, if enacted, would force Medicare to equalize payments for the same services without regard for regional differences, such as the cost of living. Each state would be reimbursed the same amount for each patient and procedure, even though costs vary widely from state to state. 

The potential effects on Massachusetts? A reduction of more than $1.1 billion in Medicare funding every year along with thousands of job losses at health care facilities across the state. Primary care physicians and nursing homes would also be affected. "The proposal does nothing to control health care costs or improve coordination of care," they write. "This provision just shifts the same money around the system, resulting in a less rational allocation of resources….[and] residents in Massachusetts and 13 other states will suffer significant losses in jobs and, thus, in access and quality of care."

Read A formula to hurt Mass. hospitals

Update of September 8: The New York Times reports on the issue.
Read: Data Fuel Regional Fight on Medicare Spending

On PBS: Great Coverage of the Primary Care Shortage in Massachusetts

Posted in Health Reform, Primary Care on January 7th, 2009 by MMS – Comments Off on On PBS: Great Coverage of the Primary Care Shortage in Massachusetts

The PBS "News Hour" with Jim Lehrer did an outstanding job last night covering the serious crisis in primary care here in Massachusetts.

Reporter Betty Ann Bowser visited Dr. Kate Atkinson's family medicine clinic in Amherst, spoke with medical students at Boston University, and interviewed MMS President Dr. Bruce Auerbach.

The story is a rare treat: Nearly nine minutes of TV journalism (!), doing justice to an important and complex subject.

If you missed it, PBS offers the following: