Each Patient Counts: Massachusetts Medical Society Weblog

More Evidence of a Primary Care Crisis

Two great articles in the Boston Globe today about the primary care crisis.

First, In the Globe's West Weekly edition, "A Bug in Healthcare Law" discusses how there aren't enough physicians or other clinicians to handle the 300,000+ newly insured people in Massachusetts. It focuses on the community health centers in the MetroWest area, but it could apply to anywhere in the state. It validates what everyone in the business has been saying for the last few years. The print version is available only if you subscribe to the Globe's West Weekly edition. However, it is available to everyone on the Globe's website.

Second: You must check out today's elegant article about the crisis in primary care medicine in the Globe's op-ed section. Though prosaically titled "The Crisis of Primary Care Physicians," Annie Brewster's article is elegiac and poetic. It is an absolute gem.

Dr. Brewster used to be a primary care physician, but she is now an urgent care physician at MGH. I haven't read a better essay on why patients and physicians feel ripped off by the continuing demise of primary care.

Take a minute or two and read it. I guarantee that you will be moved.

- Frank Fortin

Mass. Medical Society Files Legal Action Against the Group Insurance Commission

The Massachusetts Medical Society announced today that it has filed legal action seeking to “correct the wrongs” of the physician ranking program implemented by the Massachusetts Group Insurance Commission (GIC), the purchaser of health insurance for most Massachusetts state employees and retirees.

The complaint, filed in Suffolk Superior Court, alleges that patients have been defrauded and harmed and physicians have been defamed by the GIC’s Clinical Performance Improvement initiative (CPI), a program that ranks (or “tiers”) individual physicians in one of three tiers, using various cost and quality measures. Patients are charged higher co-payment fees to be treated by physicians assigned to the lower two tiers, or must try to change physicians to avoid higher co-payments.

The filing asks the court to either stop the tiering program, or to require that the CPI adhere to specific standards, including transparency, fair notice, formal feedback and correction processes, meaningful physician involvement in the development of the CPI, demonstrate the program’s accuracy, validity and reliability, and submit their programs to an independent oversight authority. These are both requests that the MMS has asked GIC to do voluntarily on several occasions.

For more, read the full news release on the MMS website.

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.