Each Patient Counts: Massachusetts Medical Society Weblog

New MMS Workforce Study Shows Continued Shortages in Mass. Primary Care

The Massachusetts Medical society's 8th annual physician workforce study has found that while fewer physician specialties are operating under severe labor market conditions than in previous years, the situation in primary care continues to weaken. The report’s key findings include:  

• The primary care specialties of family medicine and internal medicine are in short supply for the fourth consecutive year.
• The percentage of primary care practices closed to new patients is the highest it’s ever been as recorded by the Medical Society.
• 7 of 18 specialties studied have been classified in short supply, 5 fewer than last year.
• The specialty of obstetrics and gynecology was found to be in short supply for the first time in the eight years of conducting the analysis, adding to primary care difficulties.
• Recruitment and retention of physicians remains difficult, especially at community hospitals and especially with primary care.
• The fear of being sued remains as a substantial negative influence on the practice of medicine, affecting access to and availability of physician services.

Read the study at www.massmed.org/workforce

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

A Snapshot of U.S. Physicians

"Physicians are the linchpins of the U.S. health care system because their clinical decisions affect how up to 90 percent of every health care dollar is spent." So begins Data Bulletin No. 35, the 2008 Health Tracking Study Physician Survey, from The Center for Studying Health System Change, dated September 2009. The survey covers a number of topics on physicians and their practices, including demographics, practice organization, career satisfaction, compensation, and distribution of physicians around the nation. "If policy makers are to guide the health care system toward greater value," HSC writes, "they need timely, credible information about physicians and their practice of medicine."   

AMA Holds Wide-Ranging Conference Call on Health Reform for Physicians

The AMA's immediate past president, Nancy Nielsen, MD, held the first in a series of conference calls last night for physicians about federal health reform. During the hour-long session, she deftly handled many pointed questions and critical comments about the AMA's role in health insurance reform, while acknowledging the frustrations that physicians are experiencing in their daily work.

She opened the call by outlining the strengths and weaknesses of the House reform bill, to which the AMA has given its provisional support.

Nielsen said the strengths included:

• Expanding coverage to 95% of Americans under age 65.
• Strong insurance reform, such as prohibiting pre-existing conditions.
• Increasing payments for primary care physicians, without reducing reimbursements to proceduralists.
• Replacing the flawed Medicare physician payment formula to one pegged to the increase in the GDP, plus 1% or 2% depending on the service provided

Negatives:

• Initially, there was nothing on liability reform. But now there is an amendment allowing states to explore "modest" liability reforms (defensive medicine, etc.)
• Initially, reimbursement in the public insurance option was tied to Medicare. The current version of the bill requires fees to be negotiated at market rates.
• A prohibition against physician-owned hospitals, which is very important to physicians in some areas of the country. Nielsen said the AMA has always successfully fought against this prohibition and will continue fighting it. She noted, "It's ironic that hospitals can own physicians, but some people think physicians shouldn't own hospitals."

She then answered a series of questions that had been e-mailed in advance. For example, she addressed one question criticizing the AMA for allegedly "throwing doctors under the bus," by saying she understands that doctors are frustrated and angry, "and we're tired of bring controlled by insurance companies," but this criticism is "unfair. That's an unfair foul."

She also addressed two of President Obama recent statements on physician decision-making. One was his comment at a news conference in July when he suggested doctors order tonsillectomies for financial reasons. "That was outrageous and we pushed back immediately," she said. Then she noted a comment by Obama at a public town hall, when the President implied that severe diabetics are getting amputations needlessly. "That was ugly, and we don't want to hear any more of that," she said.

She concluded the call by saying that the AMA will continue to advocate strongly for patients and physicians. "In the end, it may not be the grand vision of a few months ago, but we need to be part of it."

At the end of the call, the moderator invited participants to indicate by a key stroke on their phone whether the call was helpful. The moderator subsequently reported that 98% of those voted said the call was helpful.

Nielsen said the AMA is planning to hold similar conference calls in the future.

Listen to audio clips of the call here.

MMS, AARP Join to Urge Health Care Reform

In a unique collaboration, the Massachusetts Medical Society and AARP Massachusetts have come together to urge Congress to pass meaningful health care reform upon their return to Washington. In a commentary appearing in today's Telegram & Gazette in Worcester, MMS President Mario Motta, M.D. and AARP Massachusetts State Director Deborah Banda call on Congress "to guarantee that patients have a choice of affordable insurance options and to preserve the patient's choice of doctors - doctors who will work with patients to reach the best possible health care decisions. We must keep our eye on the goal - dependable, affordable health insurance for all Americans....With rising costs and shrinking coverage, the need for fair measures to improve health care in America has never been so urgent." The opinion piece has been distributed to some 12 daily newspapers across the Commonwealth. 

Read Health Care Reforms a Must  

NY Times Op-ed: Yes, We CAN Inprove Quality and Control Costs At the Same Time

Four of the heaviest hitters in health care policy weighed in today with an article in the New York Times about 10 communities that have succeeded in cutting costs and improving health care quality at the same time.

The regions are Asheville, N.C.; Cedar Rapids, Iowa; Everett, Wash.; La Crosse, Wis.; Portland, Me.; Richmond, Va.; Sacramento; Sayre, Pa.; Temple, Tex.; and Tallahassee, Fla.

The authors are Atul Gawande, Don Berwick, Elliott Fisher and Mark McClellan.

It's worth a careful read.

An Amazing Post on GIC Tiering By a Primary Care Physician

Dr. Sally Ginsburg, pediatrician from Longmeadow, has written an amazing post on the absurdities of the Group Insurance Commission's physician tiering program. It's on WBUR's "CommonHealth" blog. We heartily recommend a close, careful reading of her points.

She agrees that health care must be delivered more efficiently and that quality must be improved. But she cites many examples of where tiering clearly fails the test.

She concludes, "Look at where the BIG health care money is really being spent- high cost, end of life care and very costly and sometimes futile beginning of life care. Stop playing this out on the primary care physicians, before there are none of us left in the state."

The Massachusetts Medical Society has filed suit against the GIC to "correct the wrongs" of the tiering system. We contend that the GIC's tiering system is not only complex, it is impossible to understand. It is not only unfair, it is inaccurate. It is supposed to save money and reduce costs, but there is no evidence it does either - and there is a lot to suggest it actually does the opposite. It is unfair to physicians, and it misleads patients.

In December, a state judge held a hearing on the GIC's contention that the complaints of the MMS and five physician co-plaintiffs were without merit. A ruling on the matter is still pending.

Meanwhile, the GIC's health plans have released the tier designations for program's fourth year, and the inequities and inaccuracies seem as bad as ever, if not worse.

This isn't the way to address cost and quality. It's time to move on to something else.

Bruce Auerbach, MD
President, Massachusetts Medical Society

Obama's Health Care Budget: New Spending, New Cuts and Tax Hikes

The Obama administration’s budget plan this week features the creation of $635 billion “reserve fund” to pay for changes in the country’s health care system. It includes roughly equal measures of spending cuts and tax increases.

Based on various news summaries and other reports, here’s what Obama proposed. The estimated value of spending, cuts and tax increases come from the Obama administration.

New Spending

• Eliminate scheduled payment cuts to physicians. A 21% cut is scheduled for 2010; 40% over the next decade.
• Spend $330 million to address the shortage of health care providers in certain areas. This includes loan repayment programs for doctors, nurses and dentists who practice in under-served areas. Also, there is assistance for nursing schools.
• Increase cancer research spending at the NIH by $400 million to $6 billion.
• Spend $211 million at the HHS for research into autism, as well as for screening, public awareness and support services for autism patients
• Spend $12 billion in quality incentives to hospitals: $12 billion over 10 years

Spending Cuts

• Eliminate the 14% worth of higher payments that Medicare Advantage plans now get from the federal government and require them to submit to competitive bidding. Savings: $177 billion over 10 years. Medicare Advantage plans cover about 23% of Medicare beneficiaries.
• Set up a "regulatory pathway" to approve generic versions of biologic drugs developed by biotechnology companies. Savings: $9.2 billion over 10 years.
• Require drug makers to provide bigger discounts to Medicaid. Savings: $19.5 billion over 10 years
• Bundle Medicare payments for hospital and post-hospital care, to be split by physicians and hospitals. Savings: $17.8 billion over 10 years
• Cut payments for hospitals for preventable readmissions. $8.4 billion over 10 years.
• Reduce payments to home health agencies by $37 billion over 10 years.
• Use radiology benefit managers in Medicare. Savings: $260 million over 10 years
• Total value of spending cuts: $316 billion

Tax increases

• Increase top tax bracket to 39.6% (currently 35%)
• Limit deductions for mortgage interest and charitable donations by taxpayers in the top two tax brackets to 28%.
• Increase premiums for Medicare prescription drugs plans for high-earning taxpayers ($8 billion over 10 years)
• Allow tax cuts for upper income taxpayers to phase out in 2012
• Block phase out of the estate tax
• Total value of tax increases: $318 billion

What do you think? What's realistic, and what's not?

The Fine Print: What's in the Stimulus Bill for Health Care

The AMA has produced a nice list of the health care provisions in the federal stimulus bill.

COBRA

• Sixty-five percent temporary COBRA premium subsidy for workers who have been involuntarily terminated between Sept. 1, 2008, and Dec. 31, 2009. 
• Subsidy available for up to 9 months. 
• Subsidy would not be considered income for purposes of other federal/state program eligibility. 
• To be eligible for the subsidy, an individual must have a modified adjusted gross income below $145,000 (or $290,000 for joint filers); if the taxpayer’s income exceeds this threshold, then the premium subsidy must be repaid. For taxpayers with AGI between $125,000 and $145,000 ($250,000 and $290,000 for joint filers), the amount of the premium subsidy that must be repaid is reduced proportionately.

Medicaid

• $87 billion in additional federal matching funds is provided (from Oct. 1, 2008-Dec. 31, 2010).
• Increases Federal Medical Assistance Percentages (FMAP) for all states by 6.2%. 
• Holds states harmless against a drop in their FMAPs for FYs 2009, 2010, and first quarter of FY 2011 (e.g., if 2008 FMAP is higher than 2009, the state gets the higher 2008 rate). 
• States with large increases in unemployment will receive an additional FMAP increase. It is estimated that the conference agreement will provide about 65% of its spending via the hold harmless agreement and across-the-board increases, and about 35% via the unemployment-related increase. 
• FMAP increases will not apply to other parts of state Medicaid programs that are based on enhanced FMAP (e.g., DSH, TANF, SCHIP, child/family services, etc.). 
• States cannot use FMAP/high unemployment increases for rainy day/reserve fund. 
• States must maintain the same eligibility standards, methodologies, and procedures that were in effect on July 1, 2008, in order to receive FMAP increase. 
• States must comply with prompt pay laws in order to receive FMAP increase. 
• Extends through June 30, 2009, the current moratorium on 4 Medicaid regulations relating to provider taxes, targeted case management services, school-based services, and outpatient hospital services; states the sense of the Congress that the HHS Secretary should not promulgate as final the proposed regulations relating to cost limits on public providers, GME payments, and rehabilitative services. 
• Provides for a temporary increase in state Disproportionate Share Hospital (DSH) allotments for FY 2009 and 2010.

Health Information Technology (HIT)

• Provides approximately $19 billion for Medicare and Medicaid Health Information Technology (HIT) incentives over five years. 
• Creates statutory authority for the Office of the National Coordinator for Health Information Technology (ONCHIT) within HHS; President Bush created ONCHIT by Executive Order in 2004. 
• Establishes HIT Policy and Standards Committees that are comprised of public and private stakeholders (e.g., physicians) to provide recommendations on the HIT policy framework, standards, implementation specifications, and certification criteria for electronic exchange and use of health information. 
• HHS to adopt through the rule-making process an initial set of standards, implementation specifications, and certification criteria by Dec. 31, 2009. 
• ONCHIT will be authorized to make available an HIT system to providers for a nominal fee. 
• Provides financial incentives through the Medicare program to encourage physicians and hospitals to adopt and use certified electronic health records (EHR) in a meaningful way (as defined by the Secretary and may include reporting quality measures). Authorizes ONCHIT to provide competitive grants to states for loans to providers. 
• Medicare incentive payments will be based on an amount equal to 75% of the Secretary’s estimate of allowable charges, up to $15,000 for the first payment year.
  Incentive payments would be reduced in subsequent years: $12,000, $8,000, $4,000, and $2000, ending in 2015. Physicians who report using an EHR that is also capable of e-prescribing will no longer be eligible for the e-prescribing bonuses established by the Medicare Improvements for Patients and Providers Act (MIPPA); they will be eligible for HIT incentives only to avoid “double-dipping.” 
• Early adopters (including those who have already implemented HIT systems) whose first payment year is 2011 or 2012 will be eligible for an initial, larger incentive payment up to $18,000. In 2014, the payment limit for new adopters will be $12,000. 
• For eligible professionals in a rural health professional shortage area, the incentive payment amounts will be increased by 10 percent. 
• Also provides incentives for eligible physicians, hospitals, Federally-qualified health centers, rural health clinics, and other providers under Medicaid. 
• Physicians who do not adopt/use a certified HIT system will face reduction in their Medicare fee schedule payments of -1% in 2015, -2% in 2016, and -3% in 2017 and beyond. E-prescribing penalties sunset after 2014. 
• Both bills allow HHS to increase penalties beginning in 2019, but penalties cannot exceed -5%. Exceptions will be made on a case-by-case basis for significant hardships (e.g., rural areas without sufficient Internet access). 
• Federal privacy and security laws (HIPAA) were expanded to protect patient health information, including: defining which actions constitute a breach (including some inadvertent disclosures), imposing restrictions on certain disclosures, sales, and marketing of protected health information, requiring an accounting of disclosures to a patient upon request, authorizing increased civil monetary penalties for HIPAA violations, and granting authority to state attorneys general to enforce HIPAA.

Comparative Effectiveness Research

• The Conference Agreement provides $1.1 billion in funding for comparative effectiveness research (CER). 
• Establishes the Federal Coordinating Council for Comparative Effectiveness Research (FCC-CER), to be comprised of up to 15 representatives of federal agencies—at least half must be physicians or other experts with clinical expertise. 
• The FCC-CER will coordinate CER to reduce duplication of efforts and encourage coordinated and complementary uses of resources, coordinate related health services research, and make recommendations to the President and Congress on CER infrastructure needs. 
• Both the Report on the Conference Agreement and bill provide that the FCC-CER will not mandate coverage, reimbursement, or other policies of public or private payers. 
• CER will not include national clinical guidelines or coverage determinations. 
• The Agency for Healthcare Research and Quality (AHRQ) will receive $700 million for CER; AHRQ must transfer $400 million to NIH to conduct or support CER. 
• The Secretary will have the discretion to allocate $400 million for CER to accelerate the development and dissemination of research assessing the comparative effectiveness of health care treatments and strategies. 
• The Secretary will also be obligated to meet several requirements, including: contract with the Institute of Medicine (IOM) to produce and submit a report to Congress and the Secretary by June 30, 2009, that includes recommendations on the national priorities for CER; consider any recommendations of the FCC-CER; publish information on grants and contracts awarded with the funds within a reasonable time of the obligation of funds and disseminate research findings from such grants and contracts to clinicians, patients, and the general public, as appropriate; ensure that the recipients of the funds offer an opportunity for public comment on the research; and annually report on the research conducted or supported through the funds.

Repeal of the 3 Percent Withholding Tax

• The conference agreement delays, from December 31, 2010, to December 31, 2011, implementation of the 3% withholding tax on government contractors (including Medicare providers) that was enacted under section 511 of the Tax Prevention and Reconciliation Act of 2005. Section 511, which was intended to ensure that government contractors file their tax returns properly and promptly, would be tremendously burdensome on physician practices with their relatively small operating margins and the AMA has been working actively in a coalition effort to promote its repeal.

Other Appropriations

• Prevention and Wellness: $1 billion in funding for wellness and prevention programs, including $300 million for the section 317 immunization program; $50 million for state health-associated infections reduction strategies; and $650 million for evidence-based clinical and community-based prevention and wellness strategies that deliver specific, measurable health outcomes addressing chronic disease rates. 
• Community Health Centers: $1.5 billion for construction, renovation, and equipment, and for the acquisition of HIT systems, for community health centers, and $500 million for services. 
• Training Primary Care Providers: $500 million to address shortages by training primary health care providers, under Titles VII and VIII of the Public Health Service Act, including physicians, dentists, and nurses as well as helping pay medical school expenses for students who agree to practice in underserved communities through the National Health Service Corps. 
• Indian Health Service Facilities: $415 million to modernize aging hospitals and clinics and make health care technology upgrades to improve care. 
• NIH Research and Facilities : $10 billion in funding for NIH for new research grants and renovations and construction at the NIH’s campuses.

New Leadership in the Massachusetts House

The new House Speaker, Robert DiLeo, announced his leadership team today. Of relevance to health care:

• Health Care Financing: Harriet Stanley, West Newbury. She was chair of the House Health Care Committee from 2001 to 2003, and has been a member of the Health Care Financing Committee since then. She succeeds Patricia Walrath, who did not run for re-election.
• Public Health: Jeffrey Sanchez, Boston
• Financial Services: Peter Koutoujian, Waltham. He had been chair of the Public Health Committee.
• Ways and Means: Charley Murphy, Burlington. Last session's chair was John Rogers, who lost the speaker's race to DiLeo.
• Majority Leader: James Vallee, Franklin.
• Assistant Majority Leader: Ronald Mariano, Quincy. He had been chair of the Financial Services Committee.
• Judiciary: Eugene O'Flaherty, Chelsea, continues in this post.