One of the more effective health policy interventions in recent history was the introduction by Medicare, in the 1980s, of payment by diagnosis-related groups, or DRGs. Before DRGs, hospitals were paid on a cost-plus basis, essentially a blank check to do more. Under a DRG system, hospitals have an incentive to shorten the number of days patients stay in the hospital because the payment amount is fixed for each diagnosis, encouraging hospitals to manage costs and length of stay. Over the next decade, hospital days in the U.S. fell by nearly half; they remain among the lowest per capita in the western world.

In recent years, it has become increasingly apparent that many hospital patients end up being readmitted, which limits the cost savings that DRG payment might otherwise generate.

One study, conducted by Stephen Jencks, MD and colleagues using Medicare data from 2003-2004, showed that 19.6% of Medicare patients returned to the hospital within 30 days of leaving. In fairness, about ten percent of these returns were planned – for chemotherapy or insertion of a stent, for example – but the rest were readmitted for unplanned reasons that may have been preventable with the right intervention after discharge. Half of the readmitted patients had no evidence of an outpatient physician visit between the time of discharge and readmission.

Studying readmissions in detail leads to some interesting observations, some of which may seem counterintuitive. First of all more patients are readmitted after long hospital stays than after short hospital stays. You also are more likely to be readmitted if you are discharged to a rehab hospital or nursing home than you are if you go from the hospital to home. That’s because long stay patients and patients who go to a post-acute facility after a hospital stay are more seriously ill and more likely to be readmitted.

Readmission is not especially easy to keep track of either – in our fragmented system up to half of the patients that are readmitted after hospitalizations for conditions like cardiac surgery are readmitted to a new hospital rather than the one that did the surgery. There also is a lot of variation in readmission rates. Recently, CMS has taken this on as a quality measure and reports readmission rates for some diagnoses, like heart failure or acute myocardial infarction, on their Hospital Quality Compare web site.

At Partners, we have been studying our readmissions and have found that most of the ones that happen within thirty days actually occur early, in the first week or two. More than half of our readmission volume is Medicare patients even though they are a smaller share of admissions overall because older patients tend to be sicker and have fewer social supports than younger patients.

Clinicians across the country are testing different ideas for addressing this problem, from better discharge planning to supportive palliative care, improved coordination with home health services and scheduling follow-up MD visits before the patient leaves the hospital. But we have little concrete evidence to guide us toward interventions that work. Recently, an article in the New England Journal of Medicine cast doubt on the value of rigorous discharge planning as a solution, showing little correlation between the extent of discharge planning and actual readmission rates.

Other studies have achieved good results with better care coordination and early scheduled follow-up. Partners’ has joined a Commonwealth Fund/IHI effort called STARR – State Action on Avoidable Hospitalizations – which has the goal of reducing 30-day re-hospitalizations by 30 percent. The focus is on the transition out of the hospital and coordination between the acute hospital and any follow-on care as an outpatient.

A new question is whether a DRG-like payment that includes hospital costs and the post-hospital discharge interval in the fixed payment – commonly referred to as a bundled payment – could create the appropriate financial incentive to address this issue more effectively. The short answer is that it might and it may not take long to find out if it does given upcoming changes being considered in both state and federal payment policies.

Today the payment system doesn’t cover the cost of any extra effort soon after discharge and reduced readmissions actually reduce hospital revenue – not a great formula for action. A payment system that bundles readmissions and post-discharge care into a single payment makes sense and could both save money and improve care. It’s likely to be complicated to implement but it is worth trying and deserves our support.

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. Uncertainty and insecurity are already part of being sick, poor communication compounds these fears. Patients want to know that information about their history and current care is shared among all providers, that those providers have a consistent and coherent approach to managing their care and that they can trust their providers because a relationship has developed with them over time.

Jeannie Haggerty at the University of Montreal has described these three types of continuity as informational, management and relationship continuity.

Electronic health records are helping to address the need for information continuity but assuring management and relationship continuity for patients is a growing challenge. These aspects of continuity are especially important in serious, life threatening illness or for a patient with multiple chronic diseases. By definition, a cancer patient, or one with heart disease, depression and pulmonary issues, is complicated. It usually takes multiple providers to deliver the right package of services and it is very important for those providers to communicate clearly and consistently with each other and the patient. A computer cannot provide this kind of continuity.

Doctors, nurses and other clinicians have to take responsibility and learn to act in concert rather than as individuals. As an important first step, we need to find a way to measure continuity so that we can tell if interventions make it better, or worse.

Unfortunately, complexity is making the healthcare experience for many patients seem more and more like a disorganized cacophony, out of synch and jarring, no matter how well each note is played. Continuity and coordination are needed to bring coherence and harmony and they won’t come easily.

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. Only encounters and procedures are funded. Coordination of care, which can greatly benefit patients, is not. In fact, FFS works against coordination of care because savings that accrue from better coordination of care go to payers while the costs of coordination go to providers. Building care coordination in as an insurance company service, in the form of disease management, has repeatedly failed because patients appropriately want their care managed by their doctor not their insurer. A payment system that covers the cost of provider-based care coordination is badly needed: 70 per cent of costs are generated by the most complex 10 percent of patients and there is no way to cover the costs of coordinating that care under FFS.

The Payment Reform Commission in Massachusetts has proposed statewide, all-payer capitation as the solution to the flaws of FFS. Insofar as capitation funds coordination of care, this would be an improvement. But there are four reasons why capitation has such a negative history with doctors and patients and renaming it global payment doesn’t solve any of them.

The first is that the financial risk is shifted to providers but much of insurance risk is uncontrollable except at the population level (you can’t predict which patient is going to have a catastrophic illness, only that a certain percentage will). Insurance doesn’t work when doctors bear the financial risk because no doctor has enough patients to make that risk predictable.

Secondly, when you shift financial risk to individual doctors there is an accompanying incentive to avoid potentially sick and costly patients and no risk adjustment system can change that.

The third consequence of shifting financial risk to doctors is that it puts the patient and doctor at odds. Patients do not want to have their doctor financially rewarded for limiting services or encouraged to send them to a cheaper institution if there is another institution that is better. Doctors don’t want to be placed in that position either. Capitation creates an underpinning of mistrust, no matter how ethically the physician behaves or how rigorously oversight is imposed.

Finally, capitation means restricted choice. It has to, if you as a physician are at risk for all the costs your patient incurs, you must influence where they receive care, otherwise how can you hope to manage the costs?

Payment reform is a good idea whose time has come. It should take place incrementally, in steps that are logical and by transferring costs that are controllable. Transitioning from FFS to bundled payments and supporting the costs of care management through a shared savings model make more sense than a wholesale leap to capitation. Massachusetts went through that experiment in the 1990’s and the results weren’t pretty – hospital bed days declined by 33%, a quarter of the state’s hospitals closed and capital investment dried up with the result that parts of the hospital system are still capacity constrained. While premium growth did actually drop to a negative level for one year, the trend was not sustained and may have fueled premium hyperinflation for a time during the catch up period. We should try to do better this time.

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.

Importantly, this hasn’t happened by denying care, but rather by delivering more care in a more timely way and averting the costly problems that develop when the ball is dropped. This is hard work but patients and doctors are overwhelmingly positive about the program according to our surveys. Healthcare outcomes have also improved.

Several early design decisions contributed to this success. First, and unlike similar efforts sponsored by insurance companies or “disease management” firms, this program is based in the physician’s office, with additional staff whose job it is to maintain a connection to the complicated, chronically ill patient, anticipating, preventing and resolving issues before problems arise. As a result, over 90% of eligible patients chose to enroll. An electronic medical record and other e-tools are the backbone of the program, creating a single repository of all important information and alerting the care team if the patient arrives in the emergency room or has a troubling test result.

Finally, and significantly, the program makes possible the upfront investment in staff support that enables the physician to manage the care outside the traditional fee-for-service model. Without this change, our physicians would be providing more care and getting paid less, stuck in the same rut that we have been battling for decades.

Ironically, a recent Boston Globe story on our program earned mixed reviews from readers who commented. Many misinterpreted the program goals as an attempt to withhold care and missed entirely the point that, by improving systems, critically evaluating the care that is provided and increasing prospective support to the patients, we have improved quality and reduced the need for costly services after problems develop. The result is more appropriate care at a lower overall cost. Payment reform can be better for the patient and better for all of us.

David F. Torchiana, MD
Massachusetts General Physicians Organization

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 (i.e., the majority) had become insured by taking up employer based insurance, encouraged by the artfully crafted employer requirements and the individual mandate. This is the first time in decades that this state has experienced a significant enrollment increase in private, commercial health insurance. Moreover, the rate of employers offering health insurance has actually increased in Massachusetts while nationally, fewer employers are offering coverage.

Finally, and significantly, the cost of broadening healthcare coverage has been distributed equitably across the newly insured, employers and government. A recent report from the University of Massachusetts, sponsored by the Blue Cross Blue Shield Foundation of Massachusetts has shown that the proportionate cost from each of those sources is almost identical to the level prior to implementation of expanded coverage. Surveys continue to show that the overwhelming majority of state residents support health reform and feel that the state has made progress on access to care (by a factor of almost 3:1).

There are obvious financial pressures in Massachusetts but these are more related to the tormented economy and healthcare cost inflation than health reform. Unfortunately, increased unemployment and reduced state tax revenues will make the tension worse. But the truth is that the cost for the state to fund health reform has been remarkably close to what was expected. Initial state government costs were about 13% higher than budgeted because the count of the number of uninsured proved to be an underestimate and more people enrolled in subsided insurance faster than predicted. Recent annual growth for the program is down to 7%, almost exactly the same as the aggregate national figure on healthcare cost increases. Premium increases for individuals with subsidized insurance have averaged less than 5% each year, and the fund to cover the state subsidized products is actually in surplus this year – one of the rare segments of the state budget that is!

Effective cost management is needed to deal with healthcare cost trends, not just because of health reform. Price controls and rationing, as threatened in the WSJ editorial, are being actively discussed. Price controls have never worked in healthcare; it seems unlikely they will this time either. With the current zeal for government regulation, we may see price controls anyway. As mentioned in this space previously, rationing healthcare on the grounds of clinical effectiveness may sound ominous but it makes more sense than the way we ration currently based on geography, employment and socioeconomic status. It is not as though we live at rationing Level 1 with unfettered application of any therapy that’s out there and are going to leap to Level 10 where everything is rationed/planned as if in a Soviet model. There is a great deal of practical work that can and will be done on comparative effectiveness (with funding from the federal stimulus package) which will have a trivial impact on choice and a major impact on cost trend.

Extending healthcare coverage to a broader population is not the cause of medical inflation although it can be a multiplier. The real opportunity to manage costs will always comes back to coordination of care for chronic illness (remember, 70% of healthcare spending is on 10% of patients) and the removal of barriers built into the payment system that make this impossible or difficult to do. Maintaining a high percentage of uninsured is not a cost containment policy.

David F. Torchiana, MD
Massachusetts General Physicians Organization

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 – everyone thinks it should cost less but we also want every treatment to be available for ourselves and our families, regardless of cost. Although no one wants to talk about it, any effective approach to managing healthcare costs will eventually have to confront the issue of which kinds of care should be covered. The word that describes the allocation of limited resources is rationing.

Rationing happens every day – if three people eat a pizza together and there are no slices left, the pizza has probably been rationed. In US healthcare the word rationing is akin to profanity and is rarely spoken. Rationing is happening anyway; it’s just covert, controlled via access to care, most often defined by geography or socioeconomic status. In the UK, where healthcare is nationalized and a fixed budget must cover all services, the rationing of care is an explicit decision. The agency that makes this call is the National Institute for Health and Clinical Excellence or NICE.

There is a growing call for the US government to create a similar agency to examine the effectiveness of therapies and diagnostics, not just on the basis of whether they work but also on whether they add enough benefit over the existing technology to justify the extra cost. The knowledge base exists on how to do this. It is not as clear that there is the will. This sort of enterprise would cost millions to set up properly and will generate ongoing controversy and opposition from many sectors. In spite of the name, NICE is not very popular with the British public and it won’t be popular here either. The alternative that is worse is to do nothing and continue to covertly ration, irrationally.

David F. Torchiana, MD
Massachusetts General Physicians Organization

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. Reconsidering mandated benefits could lower cost but is politically charged. Setting up a center for review of clinical effectiveness to limit costly therapies and diagnostics that have marginal proven value makes sense but could be stifling to innovation and hard to do at a state level. Payment reform can theoretically create better incentives in the payment system for cost management but there are tradeoffs there as well.

Unfortunately, the area most at risk for further cuts is where short-term investments in infrastructure offer long-term cost management opportunities. Cutting support for expansion of primary care or for the extension of electronic health records are examples of short-term savings that could limit long-term gains.

One of the painful early lessons of health reform is that not only have expected reductions in emergency visits not materialized, the opposite may be happening. Formerly uninsured patients who now have coverage seem to be using ED’s more, not less. Part of this may be due to a shortage of primary care providers; but patients with primary care doctors use emergency rooms too. To reduce ED use more effort is needed to organize the care of the most complex chronically ill patients. Care coordination – to improve quality, eliminate duplication and reduce preventable ED visits and hospital stays – is essential. I’ve written here about the promising demonstration project we have underway for our most complex Medicare patients – it is possible to take better care of patients at less cost. Every provider organization needs to start tackling this problem and every payer needs to be thinking of ways to encourage better coordination of care.

We put off implementation of electronic systems, like electronic medical records and computerized provider order entry, at our peril. These tools are the cornerstones of care coordination, safer care and efficient use of resources and they need to be implemented. If we cannot hold onto the critical underpinnings needed to evolve to a more effective healthcare system, we will fail the test.

David F. Torchiana, MD
Massachusetts General Physicians Organization

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.

The case manager noticed Mrs. J’s social isolation, arranged for a social work evaluation, and linked her to a community adult day program to connect her with other seniors and reduce her isolation. She has had no further visits to the ED and overall has had fewer somatic complaints. She gets regular follow-up calls from the care team and her symptoms of depression have eased.

Mr. S and Mrs. J’s cases are typical of the complex interplay between medical and psycho-social issues that many patients coping with multiple chronic conditions have to face. Unfortunately, physician offices usually don’t have the resources to play quarterback for complex patients and anticipate or resolve these sorts of issues before they result in a costly hospital stay – one of the reasons why care for chronically ill, elderly patients has become so expensive.

Mrs. J and Mr. S are just two of 2,500 patients enrolled in a 3-year care management demonstration project at MGH funded by Medicare. The project’s mission is to find out whether more intensive management leads to better care for the sickest 5 percent of Medicare beneficiaries who account for half of the government’s health care spending. By all accounts our approach, using case management and careful tracking of the most complex patients, is succeeding in its goals: reducing costs while improving patient outcomes.

Historically, ambulatory care management has been conducted via insurance companies and been mostly ineffective. This structure was logical since insurers are the stewards of the resources needed but there’s a reason it hasn’t worked well – the principal function of insurance companies is to collect premiums and pay bills, not to manage clinical care. Care management provided by the doctor’s office is more attractive to patients because they realize that the benefits will be added to and organized by their own doctor. Our demonstration project enrolled more than 90 percent of the potential patients; typical medical management companies, working via insurers, enroll less than half.

There’s a dilemma, though: outside of a sanctioned demonstration project all of the costs but none of the savings from this sort of program accrue to the physician’s office where the savings were generated – not exactly a formula that works. Prospective, capitated payment can make the formula work but if physicians are going to take on all of the financial risk, why do we need insurance companies?

The Medicare demonstration project for high cost beneficiaries combines provider-based care management with a shared savings model that covers costs. If the performance of the program holds up and the results are confirmed at multiple sites, state government and private payers should take note.

David F. Torchiana, MD
Massachusetts General Physicians Organization

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. These “Schedule II” drugs are narcotic, stimulant, and depressant drugs like morphine, Percodan, Ritalin, and Dexedrine; medications with legitimate medical uses but with the potential for abuse. A tamper-proof paper prescription must be provided for these medications. More than 3.6 billion Schedule II prescriptions were written in 2005. The Medicaid program can’t change the ban on electronic prescribing of these medications; it’s up to DEA.

Doctors who are now generating prescriptions electronically will have two choices: go back to hand written prescriptions for controlled medications – a technique we know is less safe – or implement a way to print this category of prescription on special tamper-resistant paper. The special paper must be secured to protect against it being stolen and used inappropriately. This means installing special printers with locked paper trays and separate storage lockers to house the tamper-proof paper. At MGH alone we estimate a cost of about 2.5 million dollars to comply with this rule. There are about 5,000 hospitals in this country and hundreds of thousands of physicians’ offices. Do the math – upfront and ongoing costs will be massive.

Importantly, this policy imposes an additional deterrent to adoption of electronic prescribing and an incentive to stay with paper prescription pads for all the other prescriptions that doctors write. Senator Kerry and others have led a national effort to hasten adoption of e-prescribing. Medicare is also pushing it. We have asked DEA to allow electronic prescribing for Schedule II drugs and our state is conducting a demonstration project funded by the US Department of Health and Human Services to show how it could be done. But, as of now, the rule takes effect in October.

The authors of this new law were well-intentioned, but the rule further complicates the frontlines of healthcare delivery with a backward-looking, unfunded mandate, designed to address one issue, when a forward-looking regulation could have increased both the ease and safety of electronic prescriptions. Unfortunately, in their zeal to change and improve healthcare, government regulators, payers and employers rarely coordinate policies with each other and the big picture gets lost. All too often, the right hand doesn’t know what the left hand is doing and as a result providers are further tied in knots. So health care gets more expensive but no better.

David F. Torchiana, MD
Massachusetts General Physicians Organization

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. That’s the concept of a “medical home,” where primary care practices are supported not just for office visits to the doctor but for the effort that goes into longitudinal coordination of care as a team of providers. The Senate President’s legislation directs Medicaid to test the idea with a three-year demonstration that creates incentives for coordinated, comprehensive patient care through PCP offices. Other states and health systems are testing this — including Geisinger Health System in central Pennsylvania — with some success. In addition to improving patient care, medical homes could help us redesign primary care in ways that will appeal to the next generation of physicians.

Finally, the bill also proposes to sets deadlines for the statewide adoption of health information technology. Universal use of electronic health records by 2015 and computerized ordering by 2012 are both the right thing to do. This may be a financial burden for some hospitals, physician practices, and health centers. As a result, some financial support will be needed.

There is also a little noticed, but very important provision tucked into this section of the bill that requires a statewide standard for key administrative processes – like billing and coding. This could produce significant cost savings. One option is to follow Medicare’s policies. At the Massachusetts General Physicians Organization, if all of our multiple payers used Medicare policies we estimate we would reduce expenses equal to ten percent of our total revenue. Whether Medicare is the right template or not needs to be discussed but nothing should stand in the way of convergence and standardization as administrative costs are truly dollars wasted.

Given that the Murray proposal tries to strike the balance between competing priorities and stakeholders, there are inevitably provisions that are not as easy to support from the provider perspective. In a previous entry, I have shared my apprehension about legislating certain “never events.” There are some aspirations that we all share: that patients should never be harmed by medical care is one. Certain actions like wrong site or wrong patient surgery are both aberrant and preventable and should be singled out for attention. Infections are different – we can work to reduce their incidence and prevent them whenever feasible but as long as there is no known method that will lead to their eradication it seems fruitless to write laws that mandate the impossible.

I also worry that the increased layers of oversight proposed in the bill will lead to more burdensome regulation of health care providers but at this point everyone understands the cost pressures in the environment and accepts that all participants need to hold a line. Finally, overly stringent regulations around industry/provider relationships could threaten the healthy and appropriate research relationships that have brought us today’s medical advancements and consequently delay the next generation of progress. On the other hand, industry promotion of products direct to doctors with meals, trips and other gifts generates public distrust, raises costs and it benefits neither to continue down this path.

All in all, the Massachusetts Senate and Senate President Murray deserve our thanks and appreciation for putting all these important issues on the table, stimulating debate and, I hope, producing constructive and needed change.

David F. Torchiana, MD
Massachusetts General Physicians Organization