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…

David F. Torchiana, MD, Chairman and CEO of the Massachusetts General Physicians Organization says payment reform is critical, but it’s important not to repeat the mistakes of the past…

There’s a lot to recommend payment reform in healthcare because of the significant flaws in our current approach of fee-for-service (FFS) payment. In the opinion of many, FFS is the principal cause of medical inflation because there is a built-in incentive to do more of everything. It is certainly fair to say that pure FFS creates no obstacle to using expensive medical services, which is why utilization review and pre-authorization programs are so widespread. But it is an exaggeration to assert that healthcare costs are principally driven by doctors churning FFS business for personal financial gain. In day-to-day practice, most testing and referrals do not financially benefit the ordering physician either directly or indirectly. At least as many areas of utilization are driven solely by the incidence and prevalence of diseases (surgery for hip fracture or colon cancer) as are subject to the potential problem of provider-generated demand (spine surgery or coronary angioplasty).

The more significant problem with FFS is that it is transaction-based. Read more…

Managing health care costs by changing the way providers get paid is a hot health care reform topic. Proposals for doing so are plentiful. What if we could improve care for the sickest of our patients and also reduce costs?

Last August, I used this space to describe a demonstration project underway at MGH. Working with the federal Centers for Medicare and Medicaid Services (CMS) we have been testing whether we could better manage the care of 2,500 of our sickest Medicare patients, avoid hospitalizations and save money. Almost three years into the program, it looks like we have and CMS has asked us both to extend the program for three more years and to replicate our results at another site.

These patients and their physicians are coping with multiple complicated problems. In addition to their medical issues, half have a psychiatric diagnosis, like dementia or depression, and nearly a quarter are near the end of life and die each year. Over the course of this demonstration, we have reduced their emergency room visits, hospital stays and readmissions to the hospital. It’s not uncommon for our care teams to hear that the program has “transformed” a patient’s life. We have also covered our costs and produced net savings compared to a rigorously selected matched control population. Read more…

A recent Wall Street Journal (WSJ) editorial on federal health reform decried the Massachusetts version as recklessly out of control and warned the rest of the nation to avoid such liberal delusions. For those that missed it, the subtitle under the headline was “The Massachusetts debacle, coming soon to your neighborhood.” Chapter 58 was passed three years ago this month, and it’s clear the WSJ is voting thumbs down. It is worth looking at some facts on how things are going — given the federal health reform agenda the Massachusetts model will get a lot more attention, both good and bad.

There are 432,000 newly insured by the most recent estimate. That means 97.4% of Massachusetts residents are insured, more than any other state in the US and close to the levels in the Netherlands and Switzerland where universal health care coverage is the law.

The WSJ noted that only 21,000 of the newly insured had obtained insurance privately in the free market via the Connector products, but that 165,000 were insured via free or subsidized government programs. What they neglected to mention was that nearly all of the rest Read more…

There are many demons in the popular lore on American healthcare – bean counting hospital administrators, greedy doctors and sleazy malpractice lawyers – but the most infamous evil doers of all are probably the heartless insurance companies who are criticized for denying needed services to their subscribers to feed the corporate bottom line. In reality, drawing the boundaries on what medical services to cover is a very difficult and thankless decision. Everyone knows the anecdotes – like saying no to a mom of three who has metastatic breast cancer when there is an expensive new protocol that might offer hope. But there are other variations on the theme – what “non-traditional” therapies ought to be “covered” by private or government payers: acupuncture, chiropractic therapy, infertility treatments may be ok but what about aromatherapy or cosmetic surgery or chelation?

The other challenge to coverage decisions is that the healthcare universe is constantly moving forward. Around the edges of current practice there are innumerable alternative approaches pushing to enter the mainstream, often backed by industry, specialty medical societies and patient advocacy groups. Many are advances or at least have the potential to be, and we want these new answers, sometimes desperately. The problem is we can’t afford them all and, if we could, many wouldn’t turn out to be worth the money.

The US public votes a split ballot when it comes to healthcare Read more…

Over 430,000 Massachusetts residents are newly insured since the health reform legislation was signed into law in 2006. One mostly unnoticed aspect of this story is that the percentage of employers offering health coverage to their employees has been steady at around 70%, not declined, as was feared. In total, 159,000 of the newly insured have obtained coverage via their employer, far more than anyone anticipated. This is a major incremental contribution from business (estimated at as much as $750 million in new employer contributions) to the funding of health care in Massachusetts, money that potentially saves state government from paying additional subsidies for low-income workers. A catastrophic downturn in the economy will put this progress to a serious test. If Massachusetts health reform survives the next few years it should be able to survive anything.

There are a limited number of ways to cut outlays for health care. The simplest is to cut payment rates. That’s started already with the 9C cuts and will undoubtedly continue. This approach has limits as government rates are already below costs for many providers, leading to cost shifting into commercial premiums. The next lever is to make eligibility standards for state programs more restrictive and begin to drop patients from coverage. While this is technically feasible, it is virtually impossible to contemplate as a first line measure given all the recent focus on improving access and extending eligibility.

A final set of options centers on policy initiatives. Read more…

Mr. S, a 58-year-old patient, arrived in his physician’s office. He had a history of stroke that limited his ability to communicate, a seizure disorder, and has been coping with a weak dilated heart and atrial fibrillation. He lives independently and his heart rate had been well-controlled for years with atenolol. On this visit he was experiencing rapid atrial fibrillation. With difficulty because of the communications barrier, the clinical team determined that Mr. S had stopped all of his medications, including his anti-seizure drugs and atenolol, several days earlier.

Fortunately, his physician had access to a case manager who could focus on sorting out the problem. It turned out that Mr. S’s eligibility for supplemental Medicaid benefits had lapsed and his prescriptions had been denied. Because of his speech challenges, he couldn’t effectively alert anyone to his situation. The case manager was able to re-enroll him in Medicaid within 24 hours, and get him bridge doses of his medicines from the pharmacy. His heart rate was subsequently controlled, and he did not develop new seizures. An emergency room visit and, probably, a hospitalization were avoided.

Mrs. J, a depressed, 92-year-old patient who lives alone with no family in the region had chronic numbness in both legs and faced a different set of challenges. Her doctor figured out that a B12 deficiency was likely the cause of her symptoms and initiated appropriate treatment. Unfortunately, even thought the treatment was known to take weeks to months to improve the symptoms, Mrs. J began calling the office with increased frequency, with nonspecific complaints, and twice went to the hospital emergency room about her leg numbness after she had been started on the right medications to address the issue. Read more…

There are many reasons why healthcare costs are growing so fast. There is one set of causes that should be particularly frustrating: well-intentioned but ill-conceived regulatory changes that aim to fix one problem but inadvertently create others. A case in point is the recent Medicaid requirement for “tamper-proof” prescriptions. Designed to curtail narcotics abuse by making prescribing less prone to forgery (a good thing), the rule substantially increases costs and complexity for hospitals and physicians who have adopted electronic prescribing.

Last May, this new Medicaid rule was tucked into an Iraq war and Katrina recovery funding bill. On October 1, 2008 the use of tamper-resistant prescription pads becomes mandatory to prevent unauthorized counterfeiting, copying, erasure or modification. This is fine for those who are still hand writing prescriptions (all you need are special paper pads) but what are the consequences for electronic prescribing – the efficient, modern, safer approach to ordering medications?

Unfortunately, the US Drug Enforcement Administration (DEA) doesn’t allow physicians to electronically prescribe certain medications. Read more…

The health care legislation introduced last month by Senate President Therese Murray contains some very positive policies that I hope will make their way into law: improving primary care access, testing the concept of a “medical home” and mandating adoption of technology that has been shown to improve quality, safety, and efficiency.

With an additional 300,000 people now insured thanks to the 2006 health care reform law, we need to make sure that their care is effectively managed. The Bank of America and the state have already made an important contribution – financing loan forgiveness programs for new primary care physicians (PCPs) who agree to practice in areas of high need. The Murray bill goes several steps further, authorizing the state’s medical school to increase its primary care class, offering more loan forgiveness, organizing recruitment efforts and dealing with housing affordability. It’s a balanced approach, also increasing loan forgiveness for nurses and expanding the role of nurse practitioners and physician assistants in primary care. Access is one of those problems we have to keep chipping away at to solve and President Murray’s bill knocks off a big chip.

Another creative idea for improving primary care is also in the Murray bill. Read more…

We all know that cost management is important to the success of Massachusetts health reform and that there are a lot of ideas out there. One that nearly everyone agrees on is the need for greater health information technology (HIT) adoption, particularly electronic medical records (EMR) and computerized provider order entry (CPOE).

The New England Healthcare Institute released a report last week that showed that universal adoption of CPOE across Massachusetts would save $170 million a year and avoid 55,000 potentially serious adverse drug events. That means each physician could expect to avoid 9 adverse drug events a year and could prevent three life-threatening ones every five years. Only 10 of 73 Massachusetts hospitals have adopted CPOE at present. The promise is just as great with EMR and the adoption rate just about as grim. Read more…