Each Patient Counts: Massachusetts Medical Society Weblog

Shattuck Lecture: Some Heat, Some Light, Some Answers

The New England Journal of Medicine's 118th annual Shattuck Lecture this morning approached a familiar topic - improving health coverage for Americans - in an unconventional, and sometimes exhilarating fashion.

NYU Law Professor Arthur Miller led 13 nationwide experts in a Socratic-style dialog on many of big issues dogging the health care system. To my eyes, the biggest winner from the dialog was the nearly unanimous support for the advanced medical home payment model, developed by several primary care specialty societies. Several speakers today said that the medical home model could save primary care as a medical specialty, as well as improve the care provided to Americans.

Reed Tuckson, chief medical officer at the parent company for United Healthcare, hailed the medical home payment model as a "rational model" that will help medicine "do the right thing the right way."

Charles Baker, CEO of Harvard Pilgrim Health Care, said, "Primary care needs to be treated with more respect by the payers, especially Medicare, which sets the rules for everyone."

William Frist, heart and lung transplant surgeon, former U.S. Senator and a former Shattuck Lecturer (2005), warned however, that any payment reform must deal with the inexorable rise of health care spending. With long-term prremium increases outpacing wage hikes by a factor of three, he said, the "internal costs" of health care must be addressed.

Information technology as a solution to the problems won only muted support. Baker said that technology companies "over-promised" the financial benefits and the ease of installation and use. He said that health care a far more complex enterprise than any other industry (such as financial services) that has transformed itself through information technology. "This problem is real," he said. No one in the room disagreed, and others pointed out the sharp productivity loss that many practices experience for the first year after installing an electronic health record.

By far, the most criticism was reserved for the health policy platforms offered by the three remaining presidential candidates. No candidate escaped unscathed.

Susan Denzter, editor in chief of Health Affairs, said "All of these plans have a substantial element of unreality about them." She said that they suffer from a "fantasy" rooted in a deep lack of knowledge of health care, and an adherence to the "holy writs" of each party's ideology.

Baker said real reform will only come when there is authentic political commitment to reform. He said, "I don't believe currently that any of the candidates seem prepared to stake their presidency on this. And until this happens, it's not going to happen." Tuckson added, "It will require multiple stakeholders prepared to go with their second choice." Were these comments a reference to the formula that led to health reform in Massachusetts? No one said so explicitly, but I wonder if they were thinking about it.

Is business willing to join the reform effort? Robert Galvin, MD, director of global health care for General Electric, said there's more appetite for change than ever. But he said that unless the issues of access and costs are addressed adequately, "it will be difficult to sway business that what's on the other side won't be worse than what we have now."

As with all Shattuck Lectures, the Journal plans to publish a summary of the proceedings. It will also post a condensed version of the video of the discussion on its website.

- Frank Fortin

Lead by Example: Choices for a Better Health Care System

Annual Education Program

The Annual Education Program, “Lead by Example: Choices for a Better Health Care System,” featured speakers who offered visions for improving U.S. health care systems.

Health economist Eric Finkelstein, PhD spoke about the effects obesity has on individuals and on the economy. Obesity is largely the result of technological advancements that have reduced the relative costs of food and lowered physical activity, he said. Dr. Finkelstein also noted that many businesses do not invest more money in obesity prevention programs and then discussed ways in which such programs might work better to make it cheaper and easier to be thin.

Assistant professor of medicine and health care systems Kevin Volpp, MD, PhD focused his presentation on financial incentives for healthy behavior. Noting that changing behaviors is the key to improved health, Dr. Volpp suggested changing the path of least resistance in favor of healthy behaviors, for example offering water in addition to soda at fast food chains, and by replacing candy and soda vending machines at schools with healthier options. While discussing incentives, Dr. Volpp referenced several studies, in one of which participants lost a portion of their own money if they did not lose weight. He found that loss aversion is a powerful motivator.

The two major concepts that professor of public health Peter P. Budetti, MD, JD discussed were market justice (health care is delivered on the basis of individual choices and resources) and social justice (where health care is allocated based on need). He said the tension between these concepts is played out in the rise and fall of health care coverage, and the medicalization of health care, which is executed by such development as direct-to-consumer drug advertisements and expansion of off-label drug use.

Director of the Agency for Healthcare Research and Quality, Carolyn M. Clancy, MD spoke about the future of health care and the foundation of health IT, specifically electronic medical records. She discussed how the health care industry can enhance and increase the quality and value of health care. She called for a health care system that includes the “rapid translation of beneficial advances or breakthroughs” and “connectivity with the biomedical enterprise.”

MMS president B. Dale Magee, MD, MS, closed the program by noting that the event did a lot to “broaden our perspective.”

If you wish to submit a post-event question, email it to continuingeducation@mms.org. Type 2008 AEP in the subject line and identify the speaker(s) who you would like to pose your question to. The deadline for emailing questions is Thursday, May 14 at noon, and questions and answers will be posted at www.massmed.org/2008AEP, beginning on Monday, May 12.

House of Delegates Concludes Session

The House of Delegates concluded its lengthy annual meeting this afternoon after adopting 24 policies and resolutions.

During its afternoon session, the House voted that the Society's incident-based peer review principles should be applied to health insurance companies, as well as to health care facilities. The House also said the Society should work with "appropriate entities" to explore the possibility of developing a process for an independent appeal and review of disputed peer review outcomes.

In another resolution, the House said that insurers seeking to recoup funds already paid to physicians and other providers should abide by the same time limit that they to providers for submitting claims. Though there are exceptions, insurers require physicians to submit claims within 90 days. By state law, insurers are required to pay clean, valid claims within 45 days of submission.

For more information, read the MMS news release.

Saturday, the topic of the Annual Meeting's education session will address how each member of the health care sharesd in the burdens and solutions for a healthy future.

The New England Journal of Medicine's annual Shattuck Lecture follows with a unique format: A Socratic-style seminar and roundtable with leading health care experts. It will be led by NYU law professor Arthur Miller, and will discuss the problems of health care access and coverage in America. A video of the seminar will eventually be posted on the New England Journal of Medicine website and made available to the general public at no charge.

House of Delegates: Morning Session

The House of Delegates spent considerable time this morning discussing how the Medical Society should assist physicians in managing their own clinical data to improve the practice of medicine. The House approved six principles for the management of the data warehouses, called clinical data repositories.

After considerable discussion, the House also recommended that the MMS initiate a pilot clinical data repository project to demonstrate how aggregated clinical data can improve medical outcomes. The resolution said the MMS could leverage existing entities that are already engaged in this activity.

The House also said the MMS should develop a business plan for an MMS-sponsored clinical data repository if other entities engaged in this activity don't adequately make the information available to physicians. Supporters of proposal said it is important for the MMS to play a direct role in helping physicians manage their own clinical information, rather than cede the playing field to other organizations.

Later in the session, the House began debating a series of resolutions focusing on the peer review process in hospitals and its potential misuse. Delegates asked the MMS to develop measures to protect physicians from inaccurately being labeled disruptive. The House also discussed the issue of "sham peer review," and referred the topic to the Committee on Ethics and Grievances for further review.

House of Delegates: Opening Session Summary

The Medical Society's annual meeting opened this morning with spirited remarks from President Dale Magee, who recounted what the MMS has been doing for several years to correct the serious problems in the Group Insurance Commission's physician ranking program, the Clinical Performance Improvement initiative.

Magee said that despite working with the GIC, its consultants and participating health plans to correct the programs, the issues are more serious than ever.

He said, "What we have got coming this July is more doctors being tiered at the individual level, measures being used that aren't relevant to the specialties that the doctors are practicing, procedures being included in physician reports that they don't perform, patients being included in reports that they don't take care of, doctors being put in tiers they don't deserve to be put in, patients being asked to pay co-pays that are higher without good justification, and the Group Insurance Commission is telling everyone this is the solution to the health care problem today."

Magee said he's received hundreds of e-mails, letters and phone calls from physicians who are upset about the CPI. "And they are asking, where is the Medical Society?" Noting that the Board of Trustees authorized legal action against the program recently, Magee said, "There are times when the right thing to do is to stop the wrong thing from happening." This remark was greeted with applause from the 200 delegates assembled.

The delegates then approved by acclamation the slate of nominees for the coming year:
President: Bruce Auerbach, MD
President -Elect: Mario Motta, MD
Vice President: Alice Coombs, MD
Secretary-Treasurer: Richard Aghababian, MD
Assistant Secretary-Treasurer: Deanna Ricker, MD
Speaker: Lee Perrin, MD
Vice Speaker: Richard Pieters, MD

Wall Street Journal: Retail Clinics ‘Not Unlike the Dot Com Bubble’

This begins to validate our position that the breathless advocates of retail clinics have oversold their benefits, particularly with regard to saving costs. If we're looking to save costs, we have to look elsewhere. Saving a dollar or two treating a sore throat isn't going to get the job done.

Read the Wall Street Journal item.

Minute Clinics: A Final Word, For Now

It’s time for us to close the loop on this chapter of MinuteClinics.

Careful readers of the MMS’ materials over the last seven months know that we had many concerns over how CVS planned to roll out these facilities. We stated clearly that if CVS wanted to call them clinics, they should act like clinics, no matter how limited their services.

I remain unconvinced that these clinics will save money, which is the hope of good people like Rick Lord at AIM. I remain skeptical that they will augment our fragile primary care system.  I am actually worried they will further undermine it. I remain skeptical of many more things, more than I have space to list.

Perhaps this is an idea that can be tried, at least for a few years, now that the state has imposed some reasonable rules for their operations. I wish the DPH and the Public Health Council would have gone farther in its rule-making, but nothing in life is perfect.

The real story here is that our often-criticized regulatory system worked. When these clinics surfaced last spring, CVS asked for a virtually regulation-free blessing from the state. With CVS’ political and economic firepower, it would not have been a surprise if they got what they asked for.

But they didn’t. A large number of responsible individuals and groups with direct knowledge of the Massachusetts health care environment stepped forward and raised many legitimate questions that slowed what seemed like a runaway train. We made strong, reasonable arguments that the application should not be fast-tracked. Then we argued that some basic, fair regulations had to be in place. The MMS is proud of our commitment to the public health, patient safety and access to quality care. And we are proud of our role in facilitating oversight of limited service clinics. DPH Commissioner John Auerbach did a great job managing the issues, and the Public Health Council did its job, as well.

The DPH will be watching what happens over the next few years, and so will we.

Bruce Auerbach, MD
President-Elect
Massachusetts Medical Society

For Success, All Must Contribute to the "Common"

By B. Dale Magee, M.D., M.S, MMS President

The state’s Health Care Quality and Cost Council faces a challenge that is bigger than the Big Dig. After all, that project took 20 years to spend 15 billion dollars. The state spends that much in health care about every four months. If our health care access legislation is to succeed, the Council must find a way to bring one sixth of the state’s economy, the state’s largest industry, under control.

At the first meeting of the Council in the New Year on January 2, Dr. Don Berwick, president and CEO of the Institute of Healthcare Improvement and an elected member of the nation’s prestigious Institute of Medicine, provided just the right analogy when he compared our health care system to a “commons” - the space at the center of colonial towns where folks would bring their livestock to graze. If everyone acted only in their self-interest, the land would soon be overgrazed and all would lose. The challenge, he said, was to find a way to inspire those involved to view their duty as not only a personal gain, but also as a contribution to the good of the community. One needed to only look at those attending the meeting - consultants and those advocating for various constituencies - to know that this would be a hard sell. But we ignore him at our own peril.

Each of us - physicians, nurses, insurers, and all involved with delivering care, as well as patients - needs to find ways to contribute to the success of this effort and put in something for the common good. Acting strictly in our own interest, or the tired old approach of saying that what helps our group ultimately helps everyone, will only give us more of what we already have - an industry that is edging out other sectors of the economy even as it delivers a service that contains too much waste. According to Dr. Berwick, the level of waste in our health care system is “phenomenally high” - accounting for as much as 30 percent of the health care dollars we spend.

The Massachusetts Medical Society has convened a group of medical directors from physician groups across the state. A retreat was held in early December when we brought in national experts to give us insight into how we can use data to understand and improve the value of the care that we deliver. We intend to build on this effort by reaching out to the plans and the state to see how we can further the agenda of bringing better value to the care that doctors deliver. Physicians, given the right information, can work to remove duplication and unneeded elements from a plan of care. And patients, knowing that their doctors rather than outsiders are addressing this issue, will be more comfortable with the results.

Dr. Berwick said that he would like to challenge all medical specialties to find ten things that they could improve upon to cut waste out of the health care system. I believe that his challenge should extend to all in health care and that the public needs to become more aware that more care does not mean better care. Those speaking up at the council need to go beyond recommending what should be done; they need to let everyone know what they will be contributing to the “common.”

This was originally posted on the "CommonHealth" blog on Jan. 8, 2008

Connector Board Cuts Some Payments for 2008

The MMS is dismayed by the Commonwealth Connector Authority’s reported decision to require insurers who bid on insurance products offered by the connector to cut provider payments next year by 3 to 5 percent. The reductions, voted on Thursday (Dec. 13), will be included in bid documents that will be issued early in 2008.

Authority members implemented the mandated provider cuts in contracts of insurers who bid to provide services to the public through the connector in order to reduce projected increases of 14 percent in payments to insurers.

The intent seems to be to lower the current fee schedules which attracted providers to the managed care contracts by providing significantly higher rates than Medicaid. New participating providers were necessary to allow the plans to have any chance of providing access to care to the thousands of new subscribers anticipated under the new law. The managed care plan rates apply both to Medicaid eligible patients and those who purchase or otherwise receive insurance coverage through the Connector.

The cuts would apply to the four Medicaid managed care health plans who also provide care to insureds. They do not apply to Medicaid fee-for-service plans, which by prior legislative requirements are scheduled to rise another $17-$19 million next year.

Until recently, the four managed care plans had offered a fee schedule above Medicaid indemnity rates for services provided to Medicaid and individuals insured through the Connector. Patrick Holland, the authority's chief financial officer, was quoted in news reports stating, “There's no justification to be paying more than Medicaid rates."

The managed care plans generally receive capitated payments from Medicaid and the Connector. Thus the costs of fees are not directly paid by the state in most cases and a 3 to 5% cut to providers may not result in direct savings to the state.

The MMS noted that the Authority’s decision will adversely impact patient access and physician practice viability, and runs counter to the Legislature’s investment and commitment to support providers who have supported expanding access to care.

These cuts, demanded by the Connector, seem poorly considered at a time when significant questions are being raised about the ability of the four plans in question to develop and maintain an adequate provider network to cover a significant increase in insured patients, their traditional Medicaid clients and expanded Medicaid populations.

Public Health Council postpones vote on limited service clinics

After nearly 90 minutes of discussion on a wide range of issues, the state Public Health Council today tabled a vote on new proposed regulations governing "limited service clinics" in drug stores and other retail establishments. The Council will now vote at its January meeting at the earliest, after amendments have been added to the regulations and selected proposed regulations have been revised.

The 13-members of the newly re-constituted Public Health Council engaged in vigorous discussion about topics that focused on quality of care and public health and safety. The public health expertise and experience of the panel greatly contributed to the quality of the debate.

Among the specific issues raising questions were the capabilities and training of on-site staff to adequately address the differences between adult care and pediatric care; the conflict engendered by the sale of tobacco products in a healthcare environment; the location of toilet facilities and waiting room areas, away from the normal retail consumer traffic; the availability of back-up and follow-up care and interpreter services if needed by the patient; how referrals to additional care would be addressed; and how the Public Health Council and Department of Public Health would handle violations of regulations. 

"The focus of today's discussion," said Bruce Auerbach, M.D., President-Elect of the Massachusetts Medical Society, "clearly demonstrated the Council's deep concerns about limited service clinics in the areas of quality of care, ensuring the public’s health through sanitation and infection control, potential conflicts of interest and patient safety. The Council is to be commended for its thoughtful approach to public health policy." 

Dr. Auerbach said that the Council pinpointed some of the same issues that have been raised by physicians, hospitals, and community health centers regarding limited service clinics. 

The revised regulations presented today to the Council followed two public hearings and a public comment period in which some 50 individuals and organizations offered testimony and comment. 

DPH Commissioner John Auerbach chaired the meeting of the council and presided over the discussion. The Commissioner identified ten specific areas for further amendments to be developed prior to next month’s vote on a revised set of proposed regulations. The identified areas were:

1. Potential conflicts of interest in siting clinics in pharmacies.
2. Requirements for a more distinct waiting area to address infection control and patient privacy.
3. Whether clinics should be prohibited in stores selling tobacco or whether a disclosure posting on health impacts would suffice.
4. Services involving disrobing were prohibited but this may need further definition.
5. Adequate credentialing of practitioners and supervising physicians must be guaranteed to ensure competence of those serving pediatric and adult populations.
6. Location of toilet and janitor facilities must be more specific.
7. Hand sanitizers may be mandated, ( The new version mandates handwashing facilities specific to examination rooms.)
8. The role of the Public Health Council in reviewing complaints and license actions will be revisited.
9. The issue of referrals of patients with needs beyond those the clinic may meet and the question of payment when services may be duplicated will be addressed.
10. Systems of quality evaluation may be mandated.