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

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

For Success, All Must Contribute to the "Common"

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

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

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

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

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

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

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

Connector Board Cuts Some Payments for 2008

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

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

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

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

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

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

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

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