Doctors’ response

Head of Mass Medical says doctors key to global payment plan

The MassINC/CommonWealth magazine forum, Global Payments: The Next Chapter in Health Care Reform?,  at Suffolk University’s Modern Theater last night was a well-intentioned and welcome event. Any dramatic change to our health care system demands vigorous dialogue and examination, and MassINC should be applauded for its effort.

Yet the event had at least one glaring omission. Absent from the panelists was a representatives from one of the groups that will be most affected by payment reform: practicing physicians. (Patients weren’t at the table, either, and, to be sure, they will be affected by any change in how we pay for health care.)

Hospitals had a voice, as did insurers, the Legislature, and the Patrick administration. But no physician voice. Hence, this column, and my thanks to CommonWealth, for allowing the physician perspective to the conversation.

Physicians are quick to agree that current health costs are unsustainable. But the rapid embrace of global payments and accountable care organizations (ACOs) as a panacea to rising health costs should be tempered by several factors.

One-size does not fit all: Physician groups (and hospitals) differ markedly in size, geographic location, patient populations, specialties, and technical and organizational abilities, and a one-size-fits-all approach is inappropriate. State figures indicate that more than 60 percent of the physician practices in Massachusetts are small  — one- or two-physician practices.

Some practices, notably larger ones with the resources to establish the necessary infrastructure such as electronic medical records, will be able to make the transition more easily and quickly. Others may find it a difficult, long, drawn-out process, and some may not make the transition at all.

The physician workforce is dependent on the number of doctors finishing residencies and fellowships who stay in the state to practice medicine and the number of doctors who retire or who choose non-clinical professions. If we force physicians to make the transition when they’re not ready to do so, we will lose those practices. Physicians will retire, move, or change employment. And the biggest impact will be on primary care physicians, already in short supply across the state, especially so in such areas as western Massachusetts and Cape Cod.  For those reasons, we believe physician participation in any new payment plan should be voluntary. And we applaud Health and Human Services Secretary Dr. JudyAnn Bigby for recognizing that voluntary participation is best.

Further, fee-for-service should still have a place in any new payment model. Geisinger Health System in Pennsylvania, for example, has demonstrated that fee-for-service can have a place in a new health care delivery system while at the same time achieving cost containment and improved quality.

Flexibility and assistance must be available: The timelines for making the transition to a new payment system must be flexible, and assistance must be available for those who need it. All providers cannot be expected to move to a system on a given date or even in a short time, as logistical capability of providers to incorporate a new payment system will vary widely. Solo and small physician practices, for example, will need help with technology and the necessary training to make the transition.   

Legal issues must be addressed: Physicians will need time and assistance to sort out a number of major legal issues that new payment structures and systems will present. ACOs — arrangements or partnerships of providers who have agreed to care for patients with improved standards of quality and reduced costs through a combination of global payments, risk sharing and coordination of care — are still undefined in law. The laws governing such complex areas as the corporate practice of medicine, self-referral, antitrust and anti-kickbacks, risk-bearing and professional liability must be reviewed carefully to see how they might apply to ACOs and affect physicians and patients.

Liability reform is crucial: Reform of medical malpractice is essential in any effort to curb health costs. Payment reform may provide incentives to provide the right care at the right time, but our legal system virtually requires doctors and hospitals to provide maximum care, even if it’s unnecessary or wasteful. The costs of defensive medicine, in this state and nationally, are huge, and any legislation calling for global payments must incorporate provisions to reduce this widespread practice. Without such protections, these legal realities could cancel out what is gained through coordinated, team-based care.

Quality measures must be uniform: Measures to judge provider quality, which will form the basis for additional payments to providers, must be uniform and based on reliable, accurate, and trustworthy data. Such experience to date, in current physician profiling and tiering programs, for example, has fallen far short of the mark.

Remember the patients: Patients – the ultimate beneficiaries of health care – will certainly be affected by a new payment system and must understand and accept any new model. That will require extensive educational efforts – by physicians, hospitals, insurers, and advocates.  

Oversight must include all stakeholders: Participation in establishing the rules and regulations of a new payment system should include representatives from all stakeholders with equal voices. This is particularly true for physicians, the ones who will make most of the clinical decisions under a new health care model. It’s only logical that they should have a voice in the decision-making process, both at the clinical level and the public policy level. 

Global payments may be seen as the next chapter in health care reform, but it shouldn’t be the final one. And it’s certainly not the only means to cost savings. Attacking administrative waste, focusing on preventive health to avoid costly chronic diseases, and improving the medical liability system to reduce the practice of defensive medicine all offer enormous opportunities for savings and cost control. 

One final note. Massachusetts has a world-wide reputation for excellence in health care, earned long ago due in large part to its exceptional workforce. Yet, some fraying has occurred. In each of the last nine years, the Medical Society has examined the state’s physician workforce and for the last 16 years, its physician practice environment. Year after year, the results of these studies have echoed a similar refrain:  Massachusetts has a physician workforce under stress in a declining practice environment. Recruitment and retention of physicians have been difficult across the commonwealth, despite our reputation. We must focus efforts to improve the practice environment and lift the image of Massachusetts as a welcoming state to practice medicine.

Meet the Author
Any change to a new system of payment for providers must be done carefully and deliberately, with flexibility, not only to avoid unintended consequences that could disrupt patient care or reduce access to care, but also to avoid damaging an already fragile physician workforce.

Dr. Alice Coombs, is president of the Massachusetts Medical Society, the 23,000-member statewide physicians organization and was the only physician on the Massachusetts Special Commission on the Health Care Payment System.