Lynn Nicholas, FACHE, President & CEO of the Massachusetts Hospital Association says serious concerns remain when it comes to revamping the current payment system to providers:

Since the Massachusetts Special Commission on the Health Care Payment System issued its recommendations over the summer, there has been a lot of pressure to act on the proposals, despite the fact that the Commission made its recommendations purposefully broad. I sat on the Special Commission and the MHA Board of Trustees, a representative sample of our member hospitals and health systems, authorized me to vote for the final recommendations, but with the caveat that a number of extremely important questions that were left unanswered in the Commission’s report would need to be addressed before the Commonwealth moved forward with specific plans or other implementation.

Our hospitals are now contemplating what they need to do to be successful in an environment that is not predominantly fee for service. Meanwhile, MHA is reaching out to other key stakeholders including legislative leaders and Administration officials to find common ground regarding workable efforts to move the reform effort forward. MHA released a white paper a few weeks ago that outlined providers’ most serious concerns about implementing payment reform; we’ll be issuing several additional papers on these “foundational” issues and suggestions for how best to resolve them over the course of the next month.

We should not let “the perfect be the enemy of the good,” as we advance toward healthcare payment reform. But neither should we ignore the complex and difficult realities we face, or gloss over the compromises that everyone will need to make in order for reform to truly succeed.

A new report by the Massachusetts Medicaid Policy Institute describes how MassHealth is well-positioned to lead the state’s transformation toward a system of global payments. Executive Director Anya Rader Wallack (also a member of the state Health Care Quality and Cost Council) explains:

There is a broad consensus that public and private payers need to better align provider payments to encourage delivery of effective, efficient and high-quality care. Among the many solutions being considered at both the federal and state levels is the use of global payments. Fee-for-service payments are the predominant model for paying health care providers in Massachusetts. Global payments have been recommended by both the Special Commission on Health System Payment and the Massachusetts Health Care Quality and Cost Council as a means of reigning in health care costs and improving care coordination.

Under global payments, providers would be paid a set amount to provide all care for a person for a defined contract period (e.g., a year or a month). With payments fixed, providers would have a disincentive to provide costly and unnecessary care. The underlying concept is that providers get a single global fee regardless of the resources a patient uses, though the payment is adjusted for some differences in patients’ health.

So, for example, under global payments doctors treating a woman who is overweight and has both diabetes and depression would receive a higher payment for that patient because she has two chronic conditions. But, because their payment is capped, they still would have an incentive to help the woman lose weight. They also would want to manage her diabetes and depression on an outpatient basis, avoiding costly complications of the diseases, including potential hospital stays. They might also include lower-cost providers such as physician assistants or nurse practitioners in the team caring for the woman.

All of these steps could reduce the total cost of care, leaving more money for either provider payments or investments in improved care. Read more…

I got a mammogram last week.

The tech person, a lovely Russian woman from Brooklyn, said she thought everything looked fine. Then, a few days later, a nurse called to say there appeared to be a tiny calcification in one breast. “Fairly common,” she said. “I wouldn’t worry too much.” She scheduled me for more imaging. This Thursday, at Mt. Auburn Hospital.

It was my first mammogram in about 8 years, since the birth of my two children.

There is no breast cancer in my family history, so I was pretty lax about getting screened again. But my primary care doctor in Cambridge kept telling me to do it, citing the previous guidelines to get a mammogram annually after age 40. I am 45.

But during the years I nursed my daughters, I kept delaying the screening. Finally, when it was clear that my breastfeeding days were over, I scheduled the test (which, for those of you who haven’t had it, is really annoying, and involves stretching and flattening your breasts over a hard surface and then squeezing them down so they sit like sandwich meat between bread.)

Last night, after reading Gina Kolata’s story in the New York Times about the new guidelines that urge women to wait until they’re 50 before getting routine mammograms, I feel like canceling my appointment.

But of course, there is the issue of the small, “fairly common,” calcification. While I am healthy, excercise regularly, don’t smoke and eat well, you never know, right?

A good friend, a 39-year-old vegetarian marathon runner, died suddenly a few years ago, due to a rare heart condition, leaving two young daughters. Another healthy friend, whose mother died of breast cancer, got a radical mastectomy and hysterectomy after learning she had the gene for breast cancer. How can I, a journalist, a mother, a curious human being, not find out what is there in my body, guidelines, or not?

Today, I kept thinking about how, despite our knowledge about science and probability, we expect medicine to be so clear, to give us straight answers and immutable guidelines. I read all the coverage on the debate, trying to better understand what to do. I talked to my mother, my husband and my women friends. They were also confused. But here I am, between two mammograms, wanting reassurance and clarity, but also understanding that it would probably be ok to wait.

Or would it?

– Rachel Zimmerman

A post-script: I just got back from my follow-up mammogram. Everything is normal. The “calcification” they saw on the initial image turned out to be overlapping tissue. Still, the changing room was plastered with black and red signs announcing Mt. Auburn’s position on the new recommendations. The hospital, siding with the American Cancer Society, is sticking with the old guidelines — routine mammograms annually for women starting at age 40. As I left the imaging center, the technician who delivered the good news waved to me and said: “See you next year.”

Mario Motta, M.D., a Salem cardiologist and president of the Massachusetts Medical Society, argues in favor of legislation that would prevent cuts of about $13,000 to each physician in the state next year:

The U.S. House of Representatives took a giant step toward health care reform on November 7 with its passage of H.R. 3962, the Affordable Health Care for America Act. But achieving meaningful health care reform still has a long way to go, and a critical part of that journey includes passing the complimentary bill H.R. 3961, The Medicare Physician Payment Reform Act of 2009. A vote on H.R. 3961 is scheduled this week.

H.R. 3962 contains many provisions that will improve patient access to quality health care. It will cover 96 percent of Americans, invest in public health and quality improvement programs, reduce administrative waste, expand Medicare coverage of prescriptions drugs, create pilot programs for malpractice reform, and underwrite improvements in the primary care workforce. These are goals at the core of health care reform, and physicians vigorously support them.

However, if H.R. 3961 falls by the wayside, or some other payment reform for Medicare doesn’t come about, much of what H.R. 3962 seeks to accomplish will be greatly diminished.

H.R. 3961 will repeal a seriously flawed formula used to set Medicare physician reimbursement rates. The culprit is something called the “sustainable growth rate” formula, introduced in a budget bill passed by Congress in 1997. While it’s a complex formula, the basic idea is that the amount Medicare pays to provide care for an average Medicare patient can’t grow faster than the economy as a whole. When the economy is good, there’s no problem.

But since 2002, the formula has called for cuts in reimbursements to physicians, and for seven years in a row, Congress has stepped in at the last minute to reverse the cuts. Read more…

Dr. Annie Brewster, a Boston internist, explores some of the real problems facing patients and their families, and concludes that fixing health care will require a profound shift in our expectations of what medicine can accomplish:

The United States health care system cannot be fixed by legislation alone. No matter what the laws say, our societal expectations, if unchecked, will ensure that health care costs continue to soar.

As Americans, we want the best health care available. Of course we do. But there is a degree of entitlement and misuse of the system. We are uncomfortable with ambiguity and do not like what we cannot control. We want answers and we want a cure. We never accept death. To contain health care spending, a fundamental cultural shift is required.

While I firmly believe that access to high quality, compassionate health care should be a basic human right, there are limits to what we should expect and hard choices to make. I write this to convince myself as well as you. Consider the following scenerios:

A 47-year-old business executive, Mrs. S., comes in to see her primary care physician for her yearly physical. Her exam, including a pelvic, is normal. She feels well. She has no risk factors for ovarian cancer, but she requests that her CA-125 level be checked, noting that she is anxious about this disease despite her lack of symptoms. The doctor explains that CA-125, a protein biomarker that can found in elevated concentrations in the blood of individuals with ovarian cancer, is not recommended as a screening test because of inaccuracy. Many people who do not have cancer will have elevated levels, resulting in expensive and potentially harmful additional testing. She has read about the test on the Internet and feels she understands the risks. She wants it done, and she is adamant. The test is ordered.

A 35-year-old female, Ms. A., is seen in clinic complaining of fatigue and vague abdominal pain. She lives alone and works as a city bus driver. She is run down and has no energy. She is sleeping poorly, has no appetite and has lost weight, but she is not vomiting or having diarrhea, and there is no blood in her stool. Her exam is normal. Blood work is normal (a blood count, electrolytes, kidney function tests, liver function tests, thyroid function tests). She is reassured by the doctor that nothing of concern has been identified and is sent home. Her symptoms continue and she returns to the clinic on multiple occasions, and is seen in the emergency room twice as well. Along the way, she has additional blood work, an abdominal CT, an upper endoscopy and a colonscopy. She is seen by a gastroenterologist, and then a rheumatologist. She admits to feeling depressed and anxious “sometimes,” but refuses a referral to counseling and medications to address these symptoms. She continues to come to the clinic, seeking answers, but there are none to be had. She wants someone to make the pain go away.

Mrs. P was a 68-year-old happily married mother of four and grandmother of twelve who developed breast cancer and died. Read more…

Nancy Turnbull, Associate Dean for Educational Programs at the Harvard School of Public Health, reports that the state student health insurance program is riddled with gaps, complications and high costs:

A recent report on the student health program (SHP) by the Division of Health Care Finance and Policy gives us one of the first detailed looks into student health insurance plans since they were mandated 20 years ago. And it’s not a pretty picture.

Some background: Most students in Massachusetts are required to have health insurance and colleges and universities are required to offer qualified student health insurance plans (QSHIP) that can be purchased by students to meet the state mandate. Only a quarter of students subject to the mandate (about 97,000 people) buy school-based insurance; most waive the school coverage because they have insurance through their parents, a spouse, or an employer.

We’ve always known that the minimum required benefits in student health insurance have some serious gaps, particularly for students who have serious medical problems. The plans were mandated as part of the state’s 1988 health reform law, with a primary purpose of getting students out of the state’s Uncompensated Care Pool. Since the state was mandating coverage, it wanted to keep premiums low, which it did by developing a minimum benefit package that would cover most of the needs of most students but not provide comprehensive coverage.

The minimum standards recognize the goal of making primary and preventive care reasonably available to students by mandating coverage and keeping the maximum annual deductible fairly low ($250). (Most schools have student health services at which students can obtain many primary care services that are financed directly by the schools rather than through insurance.)

But SHIP plans are permitted to impose limitations that are uncommon in most other types of health insurance in the state, including:

–Caps on total benefits per illness or injury of $50,000 (an annual cap of $50,000 is permitted in the state’s Young Adult Plan).
–Annual or per illness/injury limits on specific services. For example, some plans have an outpatient service cap of $1500 or a limit of $5,000 on surgeon’s fees
–No coverage is required for prescription drugs
–Limits on pre-existing conditions for up to 6 months

Many of the school plans also have complicated and high cost-sharing, especially coinsurance, which makes it very difficult for students to understand their potential liability.

Although it’s no surprise that most QSHIP plans have limited benefits, the DHCFP report provides information on the number of students affected by the limitations. For example, in the last three years, a fairly small number of students—92—exceeded the maximum benefit in their QSHIP plan but more than 4,000 students exceeded the outpatient maximums. While the numbers might seem small, students can incur significant medical debt because of these limits. Read more…

David F. Torchiana, M.D., Chairman and CEO of the Massachusetts General Physicians Organization, says without a coordinated effort by providers, vulnerable patients are left feeling anxious and confused:

Fifty years ago it was routine for a physician practicing alone to manage patient problems by relying on memory and a paper record. Medicine didn’t require a full orchestra of providers. In most cases, a “soloist” could easily find and play the correct tune. That was all that was needed. Just about everyone liked this approach; patients developed a relationship with their doctor and trusted them to provide the right care.

The practice of medicine has changed. There is so much more to know and because we have more ways to diagnose and treat illness, optimum medical practice today requires many more players. Consider this point, made by my colleagues Tom Lee, MD and James Mongan, MD in their new book, Chaos and Organization in Health Care: in 2007 the number of new scholarly articles listed in the US National Library of Medicine’s database was twice what it was in 1996.

Just as when playing music, there is a difference between an orchestra and a group of isolated soloists. The pleasing sounds of an orchestra are the result of teamwork, coordination and orchestration to get things right. Unfortunately medical practice has not kept up with the evolution of the knowledge base – most physicians still practice in a solo or small group setting and even when they are aggregated together, typically there is inadequate attention, and insufficient resources, devoted to coordination.

Failure to coordinate and provide continuity of care undermines the patient and family’s faith in the competence of the team providing care. It also can result in harm. A hospitalized patient who hears multiple different versions of their treatment plan or worse still, no treatment plan at all, is left confused and anxious. Read more…

Katy Aisenberg, a psychologist in private practice in Cambridge, reflects on recent events and the often invisible stress that mental health providers endure:

As the nation held its breath, waiting for news about health care, violent acts were committed against a caregiver to the mentally ill and by a caregiver himself. The psychiatrist in Fort Hood who shot military men and women was preceded by a more intimate tragedy. At Massachusetts General Hospital a bi-polar man, at an outpatient appointment, attacked his psychiatrist, a female doctor and was killed by a security guard who happened on the scene.

The following day I sat in my office and wondered, not for the first time, if I might get killed by a patient or have a death on my hands. And I thought (unlike many) how amazing it is that these events do not happen daily.

Mental illness shows no prejudice: it is invisible and slippery. Progress is difficult to measure and the care is given by people who are tired, severely underpaid, suffer compassion fatique and vicarious traumatization. We live in two worlds — often at the boundary of madness. Then we walk back into the bright, well-lit rooms of our homes or our children’s school and try to forget what we know.

But at such an important moment of change, as we contemplate our American health care “system” we need to review the state of mental illness. Thirteen years ago I began treating young women who were dying from eating disorders. I was tremendously optimistic about change in my field. Taboos were lifted and therapy became widely acceptable as did new and effective psychotropic medication.

Yet, in fact, the opposite has happened. I see more and younger women succumb to eating disorders. We know what treatment is but there are fewer places for this treatment. I also see the power of our modern culture: we speed up our pace of achievement but are fed less nourishment. We have less free time, vacation time, time with our own children. Rarely do we have time to read and reflect upon what we do. We refuse ourselves the precise self-care which we insist is essential for our patients.

Mental illness — the invisble dark cloak of depression, the shaking hands of the anxious, the rude voices of schizophrenia — is one of America’s untouched frontiers. Read more…

Gardiner Harris, writing in the New York Times, tries to figure out why health care reform in the State of Maine is so elusive.

Harris (my former colleague at the WSJ), says that “Maine is the Charlie Brown of health care.” He continues:

The state’s legislators have tried for decades to fix its system, but their efforts have always fallen short: health insurance premiums are still among the least affordable in the nation, health care spending per person is among the highest and hospital emergency rooms are among the most crowded. Indeed, many overhauls to the system have done little more than squeeze a balloon — solving one problem while worsening another.

In an apparent about-face, U.S. Rep. Mike Capuano says in the end, he might not vote for a health care reform bill that includes prohibitions on federal funding for abortion, according to the Boston Globe, which calls the move “a startling reversal.”

On Saturday Capuano, a Democrat who is running hard for the U.S. Senate seat previously held by the late Ted Kennedy, voted with the majority in the House to pass a health care overhaul plan that did include such restrictions. Massachusetts AG Martha Coakley, also running for the U.S. Senate, made news when she said she wouldn’t have voted for the health care bill because she objected to the abortion restrictions.

For more coverage on how abortion politics may play out as the U.S. Senate takes up health care reform, see this roundup from Kaiser Health News.