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

An Open Letter on Tiering, Physician Ranking and the GIC

This letter was sent on Nov. 28 to leaders in the business, health care, consumer and political communities of Massachusetts by B. Dale Magee, MD, MS, president of the Massachusetts Medical Society.

The rising cost of health care has become America’s top domestic issue. Each of the presidential candidates has provided detailed responses to the problem. It is dominating the editorial pages of our daily newspapers (most recently, The New York Times in a 2,000-word editorial on Nov. 25). And most seriously for us in Massachusetts, high costs are challenging the success of Chapter 58. If we do not act effectively, this great opportunity to extend health care to almost all our citizens will be severely undermined.

The rising cost of health care has become America’s top domestic issue. Each of the presidential candidates has provided detailed responses to the problem. It is dominating the editorial pages of our daily newspapers (most recently, The New York Times in a 2,000-word editorial on Nov. 25). And most seriously for us in Massachusetts, high costs are challenging the success of Chapter 58. If we do not act effectively, this great opportunity to extend health care to almost all our citizens will be severely undermined.

Addressing the cost of health care is a high priority for the Massachusetts Medical Society. I know that no single group is capable of solving this problem. Progress can only occur when those of us who are involved with health care delivery as well as those who are most affected work together.

The most visible attempt to address health care costs in our state is the Group Insurance Commission’s Clinical Performance Improvement initiative. As you know, the Medical Society has issued a detailed critique of the program – not because we want to stop the use of data, but because we want to use data that is accurate and will allow physicians to constructively change. The GIC initiative meets neither standard – not because of its intent, but because of its execution.

In recent weeks, the attorney general of New York signed agreements with five health plans to impose rigorous new standards on health insurers who rank physician performance.

The New York agreements declare, “Consumers are entitled to receive reliable and accurate information unclouded by potential conflicts of interest. The independence, integrity, and verifiable nature of the rating process are paramount.” Four health plans – Aetna, CIGNA, WellPoint and United Healthcare – will implement these standards nationwide.

The GIC initiative, as implemented, fails to meet these standards. Physicians are issued reports that they did not understand based on data that was developed with a closed, proprietary methodology. Physicians are, understandably, angry. Patients are being faced with the choice that they will either have to pay more for their care or switch to another doctor based on an unproven and inaccurate rating system. When asked what the cost savings have been thus far as a result of this program, the health plans were unable to tell us. This is not progress; this is a divisive distraction.

We in Massachusetts are accustomed to providing our people with the best in health care – the best physicians, the best hospitals and the nation’s best health plans, by many commonly accepted measures. Yet if we accept the unproven, inaccurate and potentially injurious system now purveyed by the Group Insurance Commission, our citizens will not be provided with the same high standards now enjoyed by the people of New York. This cannot be allowed to stand.

The GIC is to be commended for drawing everyone’s attention so acutely to the cost and quality issues of health care. We must now seek better ways to make progress.

In the end, the best solutions will come through all of us trying even harder to work together. For health care to achieve its potential for quality and efficiency, data needs to be shared between the plans and the physicians. Physicians must be able to use it to better a patient’s care. Ratings, if they are to be accurate and have value, will be the byproduct of the alignment of physicians, plans and purchasers, and will reflect how well we work together to maintain the public health, and care for those who are ill and injured.

Let’s do this now.

Sincerely,
B. Dale Magee, MD, MS
President, Massachusetts Medical Society

Five Insurers Now Agree to New York Physician Ranking Rules

A total of five health insurance companies -- including the top three in the country -- have now agreed to comply with rigorous new rules for physician ranking plans, setting a benchmark for the development of a nationwide standard. United Healthcare and the Group Health Insurance/Health Insurance Plan (GHI/HIP) of Greater New York this week joined Aetna, CIGNA, and Wellpoint in accepting the principles developed by New York Attorney General Andrew Cuomo.

Aetna, Cigna, United, and WellPoint will apply the principles nationwide.

The New York model expands on the principles for physician tiering programs that the Massachusetts Medical Society adopted earlier this month. The Massachusetts Group Insurance Commission (GIC) requires its participating health plans to utilize a proprietary ranking system. The system affects nearly 300,000 state and municipal employees in Massachusetts.

“While the GIC has made some changes in its program in response to physician concerns,” said B. Dale Magee, M.D., president of the Massachusetts Medical Society, “it has not been able to ensure accuracy, reliability, or validity. It falls significantly short of the New York attorney general’s mandate for these principles, as well as for independent oversight.”

Cuomo’s office drafted its model with input from the Medical Society of the State of New York, the American Medical Association, and several consumer advocacy groups. It requires insurers to fully disclose all aspects of any ranking system and hire an independent “ratings examiner” to monitor compliance.

The New York settlement agreements declare, “Consumers are entitled to receive reliable and accurate information unclouded by potential conflicts of interest. The independence, integrity, and verifiable nature of the rating process are paramount.”

“GHI and HIP believe that consumers must have access to accurate and useful information about their physicians,” said HIP’s executive vice president, Dan Dragalin, M.D.

According to a statement from Cuomo’s office, insurers will:

• Ensure that rankings for doctors are not based solely on cost and clearly identify the degree to which any ranking is based on cost;
• Use established national standards to measure quality and cost efficiency, including measures endorsed by the National Quality Forum  and other generally accepted national standards;
• Employ several techniques to foster more accurate physician comparisons, including risk adjustment and valid sampling;
• Disclose to consumers how the program is designed and how doctors are ranked, and provide a process for consumers to register complaints about the system;
• Disclose to physicians how rankings are designed, and provide a process to appeal disputed ratings;
• Nominate and pay for the ratings examiner, subject to the approval of the New York attorney general, who will oversee compliance with all aspects of the new ranking model and report to the attorney general’s office every six months. The ratings examiner must be a “national standard setting organization” and will be national in scope, independent, and an Internal Revenue Code § 501(c)(3) organization.

United Healthcare had been scheduled to start its ranking program in New York in December. It said it will comply with the agreement before launching the program. GHI/HIP accepted the agreement prior to designing its program.

Interim Meeting Update: MMS Approves New Principles for Physician Ranking Programs

The House of Delegates today approved a long list of new principles for physician ranking programs. The principles delcare that ranking programs should:

• Aim to strengthen patient-physician relationships
• Involve physicians in the design and implementation of all programs
• Use clinically important and sound performance measures
• Ensure sample sizes adequate to support meaningful data analysis
• Rely on meaningful data and analytic techniques
• Share and review data with physicians or practices prior to public release
• Ensure transparency of all quality and cost-effectiveness measures
• Identify and consider practice characteristics that may require special attention in quality and cost-effectiveness monitoring
• Use uniform reporting formats
• Minimum unintended harmful consequences
• Be pre-tested before implementation

In its notes to the House, the committee which reviewed the proposal stated, "This does not in any way endorse tiering by insurance companies."

In a statement on the passage of the resolution, MMS President B. Dale Magee, MD, said, "Physicians are concerned that the current rating system provides potentially deceptive and unreliable information to patients. This encourages a disruption to existing patient-physician relationships, and can result in patients paying more for their health care.”

He added, “Ultimately, the best solutions will come through collaboration. For health care to achieve its potential for quality and efficiency, data needs to be shared between the plans and the physicians so that they can use it to better a patient’s care. The current experiments in rating physicians are a distraction from the best uses for this data. Ratings, if they are to be accurate and have value, will be the byproduct of the alignment of physicians and plans and will reflect how well payers and physicians work together.”

He concluded, "Controlling cost in health care is everybody’s problem and physicians need to work hard to assure that issues surrounding costs are addressed in a manner that assures quality and guards against unintended consequences."

Be Part of the Cost Solution, MMS President Urges

MMS President B. Dale Magee, M.D., M.S., said Friday that physicians must actively participate in efforts to solve the problem of rising health care costs. Speaking at the opening session of the Interim Meeting of the MMS House of Delegates, “We can't just stand outside and say this isn't going to work. We have to be part of the solution,” he noted.

Following is the full text of his remarks:

I will take a little bit of time this morning to tell you what the officers have been doing over the past six months. We have done a lot. I know that most of you are aware of some of the issues. 

For instance, MinuteClinics have been a front-burner item over the past six months. And Bruce Auerbach, our president-elect, has represented us very well with regard to this issue. Our Workforce Study was released this summer and was very well received by the public and the media and is particularly important at this time with regard to Chapter 58.

There are a lot of other things I could talk to you about, but I want to focus your attention on one thing: cost and health care. We have to focus on this more than we ever have before.

As long as I have been in medicine, people have been saying that the rate of inflation in medicine can't be sustained. When I started in medical school it was 7 percent of the GDP, and they said this can't go on. It is now 16. So we've insulated ourselves from this. Medicine has gone on, our patients have done well, and it has really not been as big an issue for us as it has been for the policy people.

We have heard people that have been crying wolf. The issue is, when the wolf comes, will we know what it looks like?

Right now we are at a point in Massachusetts where municipalities are turning off their streetlights at night. They are closing libraries. The schools are cutting down on their curricula. Manufacturers are having difficulty paying the salaries of their workers and also maintaining the cost of their health benefits.

This is what the wolf looks like, and this is why right now we have to pay more attention.

Add to this the fact that Chapter 58 is mandating health insurance for everyone in this state, a good thing, something that we support and have to work to make successful. Yet so many people feel that even now with all the efforts of Chapter 58, health care insurance is still unaffordable for them. We have to pay attention. Others are. Others are offering potential solutions of things that they feel will help.

The Group Insurance Commission is offering what they refer to as the Clinical Improvement Program, which is tiering, and which all of you are familiar with and which we have looked at in great detail. We spend more time on this than any other topic of health policy at the Medical Society.

We know that the tiering program is based on inaccurate data. We know that the tiering program is based on what amounts to an experimental approach to try to rate doctors and cost shift to patients or disrupt physician/patient relationships. We are doing everything we can to inform and protect patients and to protect physicians from unfair treatment.

We have met with the Attorney General's office. We have submitted a Senate bill that will try to stop the tiering as it is right now. We have met with the plans, with the Group Insurance Commission, with Mercer, its consultant. We've brought in national experts to try to educate everyone that is involved.  

We have put articles in newspapers. We have educated the membership. We have reached out to hospital medical staffs. We are looking at everything we can to try to if not stop this program entirely, at least bring a little more reason to it.

But the fact is that the people who are paying for health insurance, the employers, municipalities, they feel that their house is on fire. And right now the only one running into the building with a hose is the Group Insurance Commission. We can't just stand outside and say this isn't going to work. We have to be part of the solution. That is what this Medical Society is working for as well.

Two weeks ago our State of the State conference focused on the cost of health care. The idea was to bring experts in around the country to give perspectives to our health policy people, give them a view so they understand what's going on so that when consultants come to them with proposals, they can understand the pros and cons a little bit better and make more intelligent decisions.

Today at the House of Delegates we are going to have a meeting looking at practical ways to handle common problems. We want each person to think about them, how they handle the problems they may see in their offices, and to have a good discussion with others regarding how others would review the same problems.

This is how we address the cost of health care at the clinical level by just exchanging information and knowing more about how others handle the problem. In December we are bringing experts in from across the country to speak to medical directors from the IPAs in this state and help to work with them to find out what data we need and how we can best use it to try to address the issues of the cost of health care.

In the spring we are going to have a Public Health Leadership Forum, which is going to look at the connection between lifestyle and illness, between illness and the cost of health care. It's not just about the care that we deliver and how much we get paid per unit of service. Rather, it's the demand for health care as well.

Ron Davis, the current president of the American Medical Association, says that about a third of the increase in the cost of health care over the past decade relates to obesity and the increased morbidity that goes with it. When schools are cutting out physical activity and people are spending two hours a day commuting and can't exercise, in many ways we are designing a community that is going to demand more health care. It's going to require more health care, and perhaps we should look at ways outside of the health care system to improve people's health and decrease the demand for services. That has to be addressed as well.

We're addressing it not just for our patients but for us. As you walked around this building today, you saw that we have a lot of exhibits. In your packets we have materials for your office. You have been given a pedometer by the Alliance. And all of these things are going to help us.

At 1:30 today we are going to have a walk around the grounds. Symbolic but important, because if you had time to spare, you should spend that time moving. So we want all of us to not only talk the talk, but walk the walk. The officers challenge you. We are going to be there. Meet in the lobby and we will go for that walk.

In summary, I just want you to know that cost is where we are focusing ourselves today. It is not an easy question. It's not going to be easy to solve, but we've got to try. We've got to be part of the solution. We have to run into that building and solve the problem, not just stand on the outside. 

When the physicians are involved in this issue, patients will feel better. They will know that they will get solutions that they can trust. They will get solutions that everyone can live with. That's what we want. 

Thank you, Mr. Speaker.

Preventive Care Works!

Dr. Sean Palfrey, a pediatrician at the Boston Medical Center and an active member of the MMS, published a great entry today on WBUR's "Commonhealth." He said that a greater investment in preventive care for children will not only make people healthier, but help control health care costs.

Here's the central argument:

"In child health, prevention is the cornerstone. Prevention is cheaper than treatment of illness, healthier children grow up to be healthier adults, and health care for children is much cheaper than health care for adults. Health care for children is an investment; health care for adults is often payment for services long overdue."

Well said!

Read the blog.

Walk-In Clinics Tie for Last Place in Canadian Satisfaction Survey

A new study in Annals of Family Medicine suggests that patients may not necessarily be satisfied with the care they would get at walk-in clinics.

The study, conducted on Ontario, Canada, measured the satisfaction levels of patients who received care at their family physician, their physician’s after-hours clinic, emergency departments, telephone advisory services, and walk-in clinics. Here are the results, on a scale of 1 to 7:

Family physician: 6.1
After-hours clinic: 5.6
Emergency department: 5.3
Telephone health advisory service: 4.8
Walk-in clinic: 4.7
More than 1 service: 4.7

It’s interesting that the much-maligned emergency department did better than walk-in clinics. The after-hours clinics in the study are staffed by physician practices on weekends and evenings, possibly the equivalent of urgent-care hours provided by many practices in the U.S.

This study was also cited in boston.com’s White Coat Notes.

Health, Safety Should Rule Clinics

By Bruce Auerbach, MD

The debate over retail health clinics in the Commonwealth is a healthy one. From the outset, when MinuteClinics filed its application to set up shop in Weymouth, to last month, when the Department of Public Health correctly recognized that the best way to evaluate this new approach to healthcare was to set new requirements for "limited service clinics" and hold public hearings on them, the pros and cons of retail clinics have been considered. This is transparency in healthcare at its best.

Proponents claim that these clinics are a key part of healthcare reform and will improve access, be convenient and affordable, and provide for continuity of care. Yet there is not sufficient evidence to support these claims.

The company's initial application was rife with requests for exemptions from state regulations on such critical issues as space requirements, infection control, and handicapped accessibility. These areas are critical to public health and safety. The regulations now under review appear to be nothing more than a conversion of this waiver application into new draft regulations to allow such clinics.

In healthcare, convenience and affordability are not always compatible with public health and patient safety. Many physicians are concerned that retail clinics, as proposed, have few provisions for sanitation and hygiene, storage and disposal of medical waste, and accommodation for the handicapped.

Further, continuity of care is not assured through such clinics. The fragmentation of care, especially for children and those who may have multiple chronic conditions, needs to be thought through carefully.

Staffing patterns are another concern. How many nurses will a supervising physician oversee? With CVS recently announcing its intention to open as many as 60 to 80 such clinics in the first year, what will be the guidelines for physician supervision of nurse practitioners? How many clinics and what geographical areas will a physician be responsible for?

And then there is the the inherent conflict of interest, where patients can obtain medications and prescription drugs from the same profit-making organization engaged in diagnosing and prescribing - something tacitly prohibited for physicians and hospitals. Prescription errors have increased in Massachusetts, and the Food and Drug Administration has reported that it has received 2 1/2 times more reports of serious health problems linked to medications in 2005 than it did in 1998.

As an emergency physician, I believe that the argument that such clinics will improve the capacity of the state's healthcare system by diverting patients from emergency departments is a hollow one. Emergency departments always focus on genuine emergencies. Any crowding that exists is not related to patients with minor ailments, but rather inadequate inpatient resources to efficiently transfer patients from the emergency department for more extensive services.

Will these clinics lower healthcare costs? While the cost per visit at such a clinic is less than other venues, there is not sufficient data to support the assertion that they are either a replacement for a more expensive visit at a different site of service, or whether the problem was so minor that the costs would have been incurred at all.

The Department of Public Health and its newly reconstituted Public Health Council are wise to proceed cautiously, through a public process, in developing regulations. Limited service clinics can perhaps play a role in enabling access for a small array of minor problems. But many physicians believe their role must be specifically stated and monitored, their integration and collaboration with the existing healthcare delivery system assured, and their participation in facilitating enrollment into our universal healthcare process mandated.

Good health policy dictates that medical clinics be established with health and safety as the top priorities and not because they demonstrate a good "business model." This is not a competitive or "turf" issue for physicians. Above all else, it's an issue of public health and safety. We must put more value on the practice of medicine and patient safety than to driving traffic into stores and selling prescriptions.

Bruce Auerbach, MD
MMS President-Elect

This op-ed appeared in the Boston Globe on Sept. 18, 2007.

Asking the Right Questions: State Releases Draft Rules for Minute Clinics

The state Public Health Council yesterday released a complex proposal to regulate the operation of "limited services clinics." CVS hopes to open the first of these clinics in Massachusetts under its MInute Clinics brand.

We are still looking carefully at the proposal, and it's too early to share our specific comments. The hearing is Sept. 5. However it's fair to say that we will continue to study them through the lens of whether they address the quality, health and safety, and continuity of care issues we raised earlier.

To our eyes, the Public Health Council is asking the right kinds of questions. The Globe's article today covered the issues pretty well. Like the council's members, we're keenly interested in how the clinics will maintain quality of care, and how they will integrate with the rest of the health care system, as imperfect as the system is. They could provide something valuable. We would like to see the clinics improve the delivery of care in the system, not aggravate the dysfunctional aspects that we all quite familiar with.

Frank Fortin
Communications Director

Podcast: Physician Tiering in Massachusetts

In July 2006, the Massachusetts Group Insurance Commission, the agency that buys health insurance for all Massachusetts state employees, launched the Clinical Performance Improvement Initiative.

This project compiles information on how individual physicians score against various cost and quality standards, then assigns lower co-pays to physicians who score well against the standards.

The program has been controversial since the start. The Mass. Medical Society has have had substantial concerns about the accuracy, relevance and timeliness of the data, and had real worries about whether it would create unintended consequences, such as driving a wedge between patients and their access to care, at precisely the moment when Massachusetts is trying to improve patients’ access to care.

In this podcast, MMS President Dale Magee, MD, discusses the GIC program, and what the MMS has been doing to ensure that it supports the delivery of good health care.

Listen to the podcast (Length 9:42) (This will open your computer's default media player in a new window)

Download from iTunes

MMS Comments on Minute Clinics at Board of Medicine

Bruce A. Auerbach, M.D., president-elect of the Massachusetts Medical Society, delivered these remarks today (July 25) at a public meeting of the Board of Registration in Medicine on the application of Minute Clinics to open a limited health clinic at a CVS store in Weymouth:

The Medical Society and the physicians of Massachusetts welcome innovations in health care. We need innovations in our health care. We all know that much in our current health care delivery system is dysfunctional. Therefore, the only intellectually honest position to take – especially in a state which is committed to making care accessible to everyone – is to support innovation. But those innovations must ensure safety, improve the quality of care, and deliver care efficiently and in a coordinated manner.

My brief comments today will focus on only two areas – the supervision of the care delivered and the continuity of care after a patient encounter at one of these facilities.

First, on the supervision of care:

The business model of the Minute Clinic is to have nurse practitioners deliver all, or almost all, of the care. Certainly, for the limited scope of conditions that these clinics are designed to accept, this is not inappropriate, on its face. Nurse practitioners have adequate training to treat many of the conditions outlined in the original application to DPH. I have great respect for and value the skills of nurse practitioners. In fact, they are used extensively in the delivery system in which I practice.

Training is not our issue – collaboration and supervision is. The original application by Minute Clinics outlined – and I stress “outlined” – an arrangement that does not appear to ensure the integrated high-quality care for which we strive. 

In what most consider the ideal model, the one that ensures quality, safety and continuity, the nurse practitioner has constant, ready access to their supervising physician. The patient also knows with which physician their nurse practitioner has a supervising relationship and to whom they can turn for issues beyond the scope of the nurse practitioner.

In other words, there is a physician-patient relationship and accountability. In many cases, these providers are in practice in close physical proximity to each other, again supporting the collaborative, consistent relationship and the consultative, supervisory role. This type of model supports quality, safe practice.

Patients do not present with a diagnosis, similar to the list of “accepted” problems for the retail clinic. They present with complaints. Every patient who presents with a sore throat does not have Streptococcus pharyngitis. Every patient presenting with red eye does not have simple conjunctivitis. Having the ready, consistent access to a physician colleague helps ensure that the sore throat that is a peritonsillar abscess and the red eye that is a herpes lesion are not missed. My 25 years of experience working alongside physician assistants and nurse practitioners has provided me with more than anecdotal examples of similar cases.

The Minute Clinic model does not attempt to mirror this ideal model nor does it appear to even meet the standards that this Board has supported in other instances when physicians who are not always on site are called upon to supervise care by nurse practitioners. The current standards not only create a mandate for a consistent supervisory relationship with the nurse practitioner, but support the link between the patient and the supervising physician.

This does not appear to be the case with the Minute Clinic model, where the physician seems to be responsible for only a sampling audit of the nurse practitioner’s activity. There does not appear to be any attempt to establish a relationship with the patient or be available for consultation. We believe the relationship intended by the Board’s standards is the one that is in the best interest of safe, high quality patient care. It should not be altered. 

Second, some comments on how these clinics should relate to the rest of our health care system.

One of the historic scourges of our health care delivery system has been its fragmented nature. Thankfully, we are starting to make some headway in reversing this direction. Chapter 58 promises to bring us even closer to our objective of providing care along an effective, efficient continuum to every resident of our Commonwealth.

One example is the concept of the Advanced Medical Home, proposed by the American College of Physicians. It’s an excellent step in the right direction. It includes a large role for nurse practitioners in settings like this – but in close association with the physician’s practice. A number of pilot programs for the Advanced Medical Home could be implemented in the Commonwealth within the next year.

Some questions that might be posed are:

• Who will be responsible if the patient worsens after their Minute Clinic visit?
• How will the entity assuming any follow-up care, scheduled or otherwise, be made aware of the evaluation and treatment rendered by the clinic.
• Will records at the, now closed, retail-based clinic be available for those providing after hours follow-up care?
• How will follow-up or more extensive care be facilitated if the patient does not have a primary care physician?

This is just a small sampling of the types of issues that concern provider groups with the proposed model. To reiterate, these are all issues with the potential to impede our progress towards the most integrated, comprehensive, coordinated, safe and high quality health care system we can devise. 

Without significant changes in its plans for physician supervision and connecting to the larger health care community the Minute Clinic model would be a step backwards, in the wrong direction -- towards more fragmentation, and away from collaboration and continuity of care. This model would undo much of the progress that the Board, our hospitals, and our physicians have made to ensure that care is not only effective, but efficient, coordinated and patient-centered.

Worth a Read: Doctors and Patients Are Becoming Strangers

A fascinating article today in the Wall Street Journal by Dr. Benjamin Brewer, an internist from Illinois. "The relationship between physician and patient, like the family farm, is endangered," he writes. "In some places, I'd say it's already extinct."

The causes are familiar to anyone in medicine. He notes that "patients pay for the churning in terms of lack of adequate follow up, lost health histories, lower quality of service and possibly poorer health outcomes." He applauds a move by the Illinois Medicaid system which links a specific patient with one main doctor. "Thumbs up," he says.

It's time to step up for our veterans

Whatever side you take on the wars in Iraq and Afghanistan, the fact remains that too often the service and sacrifice of our military men and women get lost in the noise of debate about such issues as staying or going, more troops to deploy, or more money for resources.

Remarkable advances in military medicine have meant fewer battlefield deaths, thankfully. But with the nature of today's weapons, more soldiers survive with serious wounds and impairments.

As good as military health care has been over the years, recent revelations have pointed out serious inadequacies in how our returning veterans are being cared for by the available military and Veterans Administration facilities.    

The Massachusetts Medical Society recently passed a resolution in support of quality medical care for those personnel wounded in these wars and will urge the American Medical Association to do the same.   

It's time for civilian hospitals and health care professionals to step up and help. Yes, physicians, hospitals, clinics, and allied health care workers are under stress with the day-to-day care of our citizens. But can we ignore the sacrifices that our men and women in uniform have made on our behalf? Do we not have a professional, moral, and ethical obligation to help in the treatment and rehabilitation of these brave men and women?

I certainly think so.

Hospitals and clinics could provide beds and outpatient care, and physicians could offer necessary medical expertise and advocacy, all to help ensure these heroic men and women are provided with the treatment they require and deserve.

Other health care providers - such as physical therapists and mental health professionals - can assist in rehabilitation and ancillary efforts. Whether such services are reimbursed from the government or performed voluntarily is not of paramount concern.

What matters most is helping our veterans. Let each of us ask ourselves, what can we do to help?

Let's show that we do care, that we are not aloof, that we do recognize the sacrifices of these men and women, that we are ready, able, and willing to help them in their time of need. Let's join together with all involved on a state and national level in this noble, humanitarian effort.

Hubert I. Caplan, M.D.
Internist and Rheumatologist
Newton, Mass. 

Mini-Clinics: Not So Fast!

CVS has announced plans to open 20 to 30 "mini clinics" throughout the state.

At first glance, these “mini-clinics” may seem like a good idea: convenience, extended hours, multiple locations, no long lines in emergency departments, no long waits for appointments with primary care physicians.

Not so fast.

Concern #1: Safety. We’re worried that medical care will be delivered without the knowledge of the patient's primary care physician and without the knowledge or availability of a patient's medical history. This raises the risk of medical error. Elderly persons with multiple chronic conditions, on multiple prescriptions, are even more challenging.

Concern #2: They could kill our fragile primary care system. Our primary care network is already in crisis. Allowing mini-clinics to skim the easy, less complex patients might be the death knell of primary care, and our community health centers, too. Who would pick up the slack if that happens? Our emergency departments, of course, which are already over capacity. In other words, these clinics could replace what already exists -- with something worse.

Concern #3: Conflict of interest. It’s an inherent ethical conflict when a pharmacy is located at the same site as a primary care clinic, owned by the same company. There’s good reason why most doctors can’t dispense drugs in their own offices; the same reasoning applies to mini clinics like these.

We don’t think the Department of Public Health should allow mini-clinics to cut corners on good standards that serve the public well. If such organizations want to establish clinics, they should be subject to the same rules and regulations that govern other, designated sites for medical clinics.

Kenneth Peelle, MD
MMS President

Worth a Read: Washington Post

The Washington Post has a good overview today of the services that try to rate the quality of hospital care. Reporter Steven Pearlstein does a nice job outlining the strengths and weaknesses of quality reporting.

As my colleague Rick Gulla points out, substitute "physician" for "hospital," and you have a reasonable proxy for why physicians are concerned about many of the current quality rating initiatives.

It's a lot better than the simplistic nonsense that came from former AOL honcho Steve Case yesterday, when he said, "I think it’s crazy that people can get ratings on movies and restaurants but not on doctors."  If only life were that simple ...

Of course, he's got a new product to sell -- a medical information company called Revolution Health.

Frank Fortin

Hospitals Paying for On-Call Physicians

On Sunday (April 16), the Boston Globe wrote about how some hospitals are now are being forced to pay for physicians’ on-call time, where they never did before. Reporter Chris Rowland correctly asserted that the breakdowns in our health care delivery system are the major reason why this long-held tradition in medicine is eroding.

I was pleased that Mr. Rowland asked me to discuss the trend. Unfortunately, my brief quote in the article captured only a fraction of a very long conversation.  I did say that it’s “unfortunate” that young physicians don’t provide on-call service for free anymore. After reading that, you might suspect that I’m either insensitive to the views of younger physicians, or clueless about the tensions between physicians and hospitals. I like to think that I’m neither.

It is an unfortunate situation, but for a more complex reason. The disintegrating practice environment is undermining many of the unspoken social contracts that used to hold medicine together – social contracts that have served patients well. On-call care, provided at no additional compensation, used to be one of those contracts.

But with so many physician practices on the edge of insolvency, this is now untenable. I blame no one for choosing not to do this anymore. To their credit, some hospitals recognize this, and are adjusting their point of view. I suspect that others will eventually follow suit.

Kenneth Peelle, MD
MMS President

Worth a Read: BusinessWeek on Health Care Reform

The new edition of Business Week has an article reviewing Maine's two-year-old experiment with health care reform, known as Dirigo.
As you often get with these kinds of articles, Dirigo gets a mixed review. With 13,500 new enrollees, the plan for the uninsured is "the fastest-growing insurance policy ever offered in Maine," according to Business Week. But it falls short of the goal of 31,000 in its first year.
It has an important paragraph or two about Massachusetts. It praises the Commonwealth for its universal mandate, yet we also come in for criticism.
From the article:
"You simply can't have universal access without addressing cost," says Paul B. Ginsburg, president of the Center for Studying Health System Change. "Massachusetts doesn't have any cost containment, and they are either going to have to address this issue very soon or else spend a lot more money to ensure affordable coverage."

Also in this issue, "Stopping Reform Before It Starts," an article about how the national small business lobby has declared that killing national universal coverage is its top priority.

It brings to mind the serious concerns that the Massachusetts business community had, and continues to have, about our legislation.

Digital Doctoring - A Comment

In a recent commentary in the Boston Globe, Dr. Joseph Martin of Harvard makes a good point about the importance of information technology in health care delivery. But it is important to note that most doctors practicing in this state are over 45 and that simply waiting for them to retire so that younger ones can take their place is not going to work and is unnecessary. Physicians enter medicine not only because they love medicine and treating patients but also because they look for the new challenge. Electronic Medical Records are no different than many very difficult challenges that practicing physicians master all the time. The trick is to make available to them useful software and appropriate training.

As an electronic medical record user for over five years I know that many of the products that are out there are poorly designed and physicians are right to reject them. This is not necessarily a sign of their obstinacy, but rather their understanding of what is needed for quality IT.

The Massachusetts Medical Society has recognized this issue as critical to the advancement of health care delivery and we have in place a program to allow practicing physicians the opportunity to learn about and implement EHRs which our experts have reviewed and approved. Adoption is not only moving along nicely, but I would like to note that many of the most enthusiastic supporters are over 55.

Dale Magee, MD, MS
MMS President-Elect