Each Patient Counts: Massachusetts Medical Society Weblog

Cost, Quality and Access: MMS State of the State Conference Examines Solutions to Challenging Problems

If there was a dominant theme in Thursday's State of the State conference on health care at the Massachusetts Medical Society, it was: The time for study is over. It’s time to do something.

JudyAnn Bigby, MD, Massachusetts Health and Human Services secretary, kicked off the morning with persuasive evidence that Massachusetts has achieved a great deal in expanding access. But she also pointed out the persistent disparities in health care access for minorities. She touched broadly costs and quality, offering that payment reform, expanded health IT and transparent health care information are needed to address those issues.

She also raised questions about the mismatch between the large numbers of licensed physicians in Massachusetts and the persistent shortages cited in MMS physician workforce studies. “Why the paradox?” she asked. “It’s not simply a numbers game.”

• Listen to Bigby’s presentation. (Length 35:26) (This will open your computer's default media player in a new window)
• Download from iTunes
• View Bigby's slides.

Susan Dentzer, editor in chief of Health Affairs, reviewed the literature on the causes of rising costs and suggested solutions. According to Dentzer, why are costs rising?

• advances in medical technology
• poor health status, especially obesity
• poor productivity
• no competition on prices
• Fee for service penalizes those who re-engineer their practice
• NOT: aging population, or malpractice costs

Solutions? Dentzer explored two approaches – from the Commonwealth Fund, and the Center for Studying Health System Change. These include:

• expanding health IT
• employment comparative effective studies
• patients sharing in decision making
• disease prevention
• realigning incentives
• correcting price signals, such as re-setting Medicare Advantage rates, and permitting negotiation of Medicare prescription drug prices
• payment reform – fee for service is toxic to health care

• Listen to Dentzer’s presentation. (Length: 36:45) (This will open your computer's default media player in a new window)
• Download from iTunes
• View Dentzer's slides.

Elliott Fisher, MD, from the Dartmouth Institute for Health Policy and Clinical Practice, said solutions that focus on changing individual physician behavior will provide only limited benefit. He said lasting solutions must focus on the role of the underlying local health system as the driver of cost and quality. A better approach, he offered, is to develop “local delivery systems" that are accountable for the overall cost and quality of care.

• Listen to Fisher’s presentation. (Length: 33:13) (This will open your computer's default media player in a new window)
• Download from iTunes
• View Fisher's slides.

The session ended with a stimulating roundtable discussion among Bruce Auerbach, president of the MMS; Cleve Killingsworth, chair and CEO of Blue Cross Blue Shield of Massachusetts; Donna Cupelo, New England Region President of Verizon, and Paul Levy, President and CEO of Beth Israel Deaconess Medical Center. The moderator is Jim Braude from New England Cable News.

Rather than try summarize their conversation, we suggest you listen to it. It will be worth the investment of your time.

• Listen to the roundtable. (Length 1:12:51) (This will open your computer's default media player in a new window)
• Download from iTunes 

Related blogs:

• Levy provided his view of the session on his blog, "Running a Hospital." It includes comments from Fisher in response to a reader’s question.
• Read Health Care for All’s perspective. 

Related note: The MMS and the Heller School for Social Policy and Management at Brandeis University are co-sponsoring a new CME program, "2009 Health Policy Forum." It will be held on Jan. 30, 2009 at MMS headquarters. Click here for details and registration information.

The Budget Cuts: How They Affect Health Care

Here's the Mass. Medical Society's reading on how Gov. Patrick's budget cuts will affect health care.

In general, eligibility for care and expanded coverage of the health care reform law will be preserved unscathed.

MassHealth Indemnity, which pays primary care physicians, specialists and all other providers who bill on a fee schedule, is reduced by 3.29%. On a total line item of $1,539,816,000 this cut will contribute $51 million towards the Governor’s goal of reducing spending by nearly a billion dollars.   

For Medicaid managed care, the budget is reduced by a similar percentage on total expenditures of $3.1 billion, resulting in savings of $102 million. Although big dollars, these cuts may be deceptively small, since federal matching dollars do not appear. A savings of $150 million to the state will probably require a $300 million reduction in payments to providers.

While some line items, earmarks and past increases were specifically eliminated from the budget, the MassHealth physician raises of the past three years were not. So any proposed reductions at least start from the recent increases. It is unclear exactly how the cuts will be implemented in either the indemnity or the managed care side. Will physician rates be cut? Will they be cut evenly across all specialties? Will other providers suffer larger cuts?

The MMS has participated in discussions with Health and Human Services Secretary Judyann Bigby, M.D., and will continue to do so. Dr. Bigby is well aware of physician hortages in Massachusetts and the need to maintain access to care. She is also aware of the inefficiencies inherent in cutting programs with matching fund eligibility.

Hit hard was the Department of Public Health, with cuts totaling over $28 million. Specifics include:      

• Universal immunization programs receive a 12 percent cut on $51.5 million, resulting in $5.9 million in savings.
• The $12.75 million smoking cessation program loses $525,000.
• Disease prevention programs at the DPH lose $1.3 million of their $14.7 million budget.
• Substance abuse treatment and prevention programs cut by $2.8 million.

New initiatives passed recently on workforce development and loan forgiveness are reported to be eliminated completely, but again, details are unclear and we don’t yet know the impact on direct services.

The Board of Registration in Medicine will see a 10% cut, taking $267,000 out of the Board’s state appropriations budget. The Board lives largely on fees, and is uncut in its retained revenue from licensing which is exempt from the budgetary process, and provides an additional $6 to 7 million annually.

These are just a few of the hundreds of programs that have been affected by the downturn in state revenues. The MMS will keep its members apprised of developments and will work to maintain access to critical services and the viability of physician practices.

MMS President Bruce S. Auerbach M.D. told WBZ Radio yesterday that the cuts will accentuate existing problems in the health care system. Read about his comments here.

Will Health Care Escape the Budget Ax? Two views

The Pioneer Institute today released a long list of suggestions where the Massachusetts state budget could be cut. The areas include state employment, transportation, judiciary, earmarks, prevailing wages rules, and more. There is not a single line about health care, or health care reform.

But the state HHS Secretary is talking about it. Dr. JudyAnn Bigby briefed hospital executives and others about the options and asked for ideas. It was not a happy briefing, according to Martha Bebinger of WBUR. Read her account of it on her Commonhealth blog.

Let's stipulate that 7% must be cut. What should be cut, and what should be preserved?

Clinician’s Guide to Electronic Prescribing Now Available

All of the 1,400-plus attendees at the National E-Prescribing Conference received a copy of the just-published Clinician’s Guide to Electronic Prescribing. The 40-page primer introduces the concept of e-prescribing to the uninitiated and provides concrete adoption strategies and advice for practices ready to take the plunge.

The free guide was developed with the assistance of the AMA, the American Academy of Family Physicians, and the American College of Physicians. It contains a buyer’s-guide checklist for comparing different vendors’ systems and a useful listing of national and state E-Rx  initiatives.

Download at www.ehealthinitiative.org

-- Lloyd Resnick

E-Prescribing Lessons Learned Shared in Breakout Sessions

The messages from users and implementers of electronic prescribing systems were loud, clear -- and repetitive. In real-life scenarios, repetition translates into “truth.” Here are some of the oft-cited “best practices” from breakout sessions at the National E-Prescribing Conference:

• Training in -- and use by -- all physicians and staff in a group/practice site is essential. “Dabbling” or piecemeal adoption of e-prescribing does not work.
• The e-prescribing system should interface with the practice management system.
• Notify all local pharmacies in person that you plan to initiate e-prescribing . (More than 90 percent of the nation’s pharmacies have the capacity to handle electronic scripts, but many lack actual experience.)
• The answer to the standalone versus integral-with-an-EHR system question depends on individual practice work patterns and available human and financial resources. (The CCHIT recently agreed to certify standalone e-prescribing systems, which should ease fears about interoperability among these “simpler” systems.)
• Keep a trainer (or in-house “superuser”) on-site for three to five days after you go live.
• When doing a pre-implementation cost-benefit analysis, remember to calculate annual maintenance costs. Incentives alone (from Medicare and/or any private health plan that might offer them) will probably not cover maintenance costs.

-- Lloyd Resnick

VIPs Address Big Picture at E-Prescribing Conference

While in-the-trenches experts covered the nuts and bolts of e-prescribing during breakout sessions at the National E-Prescribing Conference in Boston on October 6-7, attendees received big-picture views from high-level state and federal officials during opening and closing plenaries.

Remarks from the federal side always mentioned the 2 percent bonus from Medicare for physicians who prescribe electronically, beginning January 1. Almost all the VIPs also mentioned the down-to-the-wire agreement on the Medicaid waiver. “The recent Medicaid waiver agreement was a remarkable example of the federal government and Massachusetts working together,” said Massachusetts Gov. Deval Patrick.

The benefits of e-prescribing are rarely debated anymore. Kerry Weems, acting administrator at the CMS, said it best: “We don’t know how much money widespread deployment of e-prescribing will save, but we know it will save lives.”

Later, Massachusetts Sen. John Kerry cited a statistic that “a 5 percent increase in the use of electronic prescribing could save doctors $1 billion over five years.”

At 14 percent, Massachusetts has the highest percentage of electronic prescribing of any state in the nation. If you consider that adoption rate low, physicians nationwide have been adopting even more slowly. Taking a businessperson’s view, Rhode Island Gov. Donald Carcieri said, “The huge growth in American productivity during the last 20 years has been driven by information technology. That same opportunity exists in health care, and e-prescribing is a relatively simple IT application.”

David Brailer, M.D., former national coordinator for health information technology, characterized physician adoption as a “diffusion, not a stampede.”

During a luncheon talk, Kevin Hutchinson, founding president and former CEO of SureScripts, noted that nationwide, 80 percent of prescriptions are written by 30 percent of providers. He suggested that efforts to “convert” physicians focus on that 30 percent.

Michael Leavitt, secretary of the U.S. Department of Health and Human Services, said information technology is a crucial part of a national plan to achieve “value-driven” health care. “We don’t really have a health care ‘system’ today,” he said. “We have a robust and rapidly growing health care ‘sector.’ Electronic prescribing is one important part of transforming health care from a sector into a system.”

-- Lloyd Resnick

Physician Shortages Grow - How Do We Fix It?

The Mass. Medical Society today released its seventh annual physician workforce study. It shows a widening  gap between the demand for health care, and the ability of the physician workforce to meet that need. The shortages are critical in the primary care specialties of internal and family medicine. These are the specialties that the state is depending on to make our health care reform law a success.

The full report is available at www.massmed.org/workforce

The debate over filling the gap continues. What's your solution?