Remarks of Alice Coombs, MD

Joint Committee on Health Care Finance

October 8, 2009

Good afternoon.

My name is Alice Coombs. I am president-elect of the Massachusetts Medical Society. I am a critical care physician and anesthesiologist at South Shore Hospital in Weymouth.

I had the honor and privilege of serving on the payment reform commission earlier this year. I would like to commend Secretary Kirwan and Commissioner Sarah Iselin for their leadership during the commission’s deliberations. There were many different points of view on the commission, and they were fair and thoughtful in everything they did.

Despite our diverse points of view, we all understood that we compelling need to bend the curve of rising health care costs. We all know how health care costs are making it difficult for businesses to operate, and making it hard for families to make ends meet.

I was the only practicing physician serving on the commission, so I had the opportunity to bring my direct experience in caring for patients to the commission’s important task.

As a physician, I also see that when care becomes unaffordable, people don’t see the doctor as often as they should. They don’t take all the medication they’ve been prescribed. They let small problems become big problems. It’s a bad picture all around.

Just as important, unaffordable care inhibits the ability of physicians to care for under-served and improve the health of our society as a whole.

Our charge at the commission was to study and see if a new payment model might help bend the cost curve – and if so, which one. I voted with the majority of the commission to accept the report, because while we don’t know if it definitely work, a new payment model is certainly worth looking into if -- and only if -- there is adequate time, support and preparation for making this enormous transformation. I’ll talk more about that in a moment.

I was a commission member and am now an officer of the Medical Society. So I had the privilege of meeting extensively and speaking with many, many physicians around the state about payment reform.

When the commission was meeting earlier this year, we went to forums throughout the state to hear what our physicians had to say. We also worked with the commission and brought together dozens of physicians to talk about the challenges they face, and to test some of ideas we were discussing at the commission meetings. They were hospital-based physicians, specialists, community physicians. All of their comments were very insightful and very, very valuable.

Their wisdom was brought back to the commission, and played a big part in many of the findings and recommendations. I couldn’t have done my job as a commissioner without them.

We heard a number of things from them.

They said that “one size does not fit all.”

The dose of an anesthetic I would use for 40-pound kid is different from a 200-pound adult.

 The health care system in Massachusetts is too diverse to impose a single solution on everyone. Specialties are different. Practices throughout the state are different. Patients are definitely different. And the economic conditions are different.

The diversity of our health care system is one of our strengths, and my colleagues said we must take this into account when thinking about new payment models. We need a nuanced approach, if we are going to make our health care system better.

They also said there is a serious primary care crisis in Massachusetts, and a new payment model must improve the status of primary care throughout the state.

In my opinion the deficit in primary care medicine severely limits our ability to provide optimal access to optimal health care.

They said physicians need lots of financial support, and they need lots of help getting the expertise to make any transition, whether it’s to global payments or anything else.

For example, the expertise and capital needed to install electronic health records alone is huge. We know lots of practices have tried to install EHRs in their offices in the last few years, and many have failed. It is a very difficult task, and the margin for error is very wide. And EHRs are just one of the prerequisites for a redesigned health care system.

My colleagues said that physicians and hospitals will have to organize themselves differently. But this will not be possible without substantial changes in state law.

Medical Liability is like  an infectious disease which fuels cost escalation. The medical liability climate in this state encourages the practice of costly, wasteful defensive medicine. Our own study at the medical society provides plenty of evidence for that assertion.Of note: 83% of physicians said they practice defensive medicine, which adds billions to health care costs. We need laws that allow the physicians to do what’s best for the patients, without looking over her shoulder to worry what could happen in a court room years into the future.

The administration cost of health care is paralyzing cost containment. It’s a no brainer. Our physicians said this must be addressed if payment reform is going to succeed.

Most of all – and I hear this from my friends and colleagues in medicine every day … physicians have been saying: “We’ve tried this before. It was called capitation, and it didn’t work.” In fact, for many physicians, it was a financial disaster. They ask me, “How can we sure this will be any different?”

Physicians are not amnesic. “They remember.”  They ask,

• How will practices be protected against undue financial risk?
• How will physicians get enough resources to provide the right care?
• How will patients trust a system that strives for optimal care, not just maximalist care? We know that evidence based medicine doesn’t always call for the most care; it calls for the right care. Sometimes over-treatment is just as harmful as under-treatment. Patients may not be used to that idea, and when faced with that, they may worry that they won’t get what they need. We have to deal with that.

Quite frankly, the commission didn’t have the time or resources to get into all of these concerns. The report does make a distinction between insurance risk and performance risk, but didn’t go into a lot of detail. A lot of work is needed to determine what this means, and how it would work.

Because of the commission’s mandate, there were many other things it didn’t have enough time to explore adequately. But I believe the Legislature has the opportunity and the duty to be more thoughtful and comprehensive in its approach.

For example, the commission didn’t spend very much time on episodes of care – this is the model where payments are bundled around a patient’s diagnosis, rather than allocated for every single action. This approach encourages the right care, while acknowledging that every diagnosis is different.

The state’s own research proved that a relatively small handful of conditions account for a disproportionate share of health care spending. For example, just 25 diagnosis groups accounted for almost 3 BILLION dollars of hospital spending in this state in 2007. That’s more than one third of all hospital spending. These include things like joint replacements, heart failure, and c-sections.

The commission didn’t study this approach in much detail, but these are the largest cost drivers in our system, and an opportunity for real savings.

One place where the Legislature could start would be to establish several rapid-test pilot projects around episode-group payments like these. In a short period of time, we could learn a lot what works, and save millions of dollars. It would also give practices and hospitals lots of experience with new payment models, and would minimize the risk of negative disruptions in patient care.

Finally, I want to put in an urgent plea that practicing physicians be named to the oversight authority for payment reform, with full voting rights and full power to make policy.

One thing we learned at the commission is that voice of the practicing physician is absolutely essential to developing a system that will work. At the end of the day, physicians will be the ones expected to work with a new system. It only makes sense that we help design it, too.

As my colleague Dr. Motta said, we’ve demonstrated that we can active partners in designing a better health care system. We’re ready to work with you on the next steps.

Thank you for your time.