Address by Ronald W. Dunlap, MD, president of the Massachusetts Medical Society, during the opening session of the House of Delegates at the MMS' 2014 Annual Meeting.
As we conclude a very busy and challenging year, I would
like to bring you up to date on five important issues.
- Medicare
and the SGR
- ICD-10
- EHR-Meaningful
Use requirements
- Medical
marijuana
- Health
Care Reform and Chapter 224
First, Medicare payments and the SGR.
We are now working under the 17th patch in the Medicare
payment formula enacted over the last 11 years. This latest patch expires in
less than a year - April 1, 2015.
We had legitimate reason to believe that this year would be
different.
We had a bill that both political parties supported, in both
houses of Congress. It had a smaller price tag than ever before, and it was an
improvement in policy:
- It
offered incentives for practices to try new payment models.
- It
provided bonuses for meeting certain quality measures, and streamlined the
reporting process.
- It had a
provision that maintained the fee-for-service system with incentives for
improve quality, thus avoiding wholesale disruptions to the provision of health
care.
It offered an evolution, not a revolution. We supported it,
along with AMA.
But when the time came for Congress to vote, each political
party reverted to partisan jousting, and the bill did not pass. Therefore we
ended up with another patch, again postponing reconciliation of the SGR.
Some day, I hope this framework will become law. I don’t
know when, or how.
I do think we’re going to have to take a different approach to ensure that the interests of 60 million seniors and
military families are more considered important to Congress than the opportunity to score a few political points for
the next election.
The patch included – in a last minute addition – a one-year
delay in the rollout of ICD-10.
This was good news for smaller, and midsized groups that are
mostly independent practices who were struggling to get ready for the deadline.
ICD-10 is a leading example of the many administrative
burdens that have multiplied in recent years, both federally and here in
Massachusetts.
One particular egregious example of bureaucratic overreach
here in Massachusetts is the complexity of regulations proposed to register
risk-bearing provider organizations by the Health Policy Commission.
Originally this provision was intended as a way to help
state government keep track of the financial and organizational infrastructure
of those taking on risk, given all of the alignment, mergers and consolidations
that have taken place across the Commonwealth.
But the regulations went far beyond those basic objectives.
Instead, they required information that is so detailed that
even a large organization like Atrius said it would struggle to comply.
We testified that this regulatory overreach would add to the
cost of practicing medicine, possibly accelerating the consolidation of the
health care market.
This is ironic, given the desire of some policymakers to put
the brakes on proposed mergers and consolidations.
Like much legislation, this regulation was drafted with
little consideration for the unintended consequences. Every additional
regulation takes us further away from actually practicing medicine, but this
evidently was not a primary concern of those who wrote the rules.
Another example of this bureaucratic overreach is that
Chapter 224 ties our bi-annual license renewal to the demonstration of
competency in the use of electronic health records. The author of the law insists that mere utilization of an
EHR is a synonymous with improving the delivery and quality of health care.
In fact, there is little evidence to support that notion or
hypothesis.
But that didn’t stop the Legislature from voting it into
law, while insisting on strict regulations to enforce it.
If strictly interpreted this requirement would mean that
unless a physician was personally certified for the federal Meaningful Use
standard, he or she could not be licensed to practice medicine.
Even in a state with one of highest EHR adoption rates in
the country, this requirement would cause more than 10,000 doctors to lose
their licenses, through no fault of their own.
By law, many of them could never qualify for Meaningful Use
standards. Meaningful Use was designed to be an incentive program, not a
certification standard.
Establishing it as a proxy for our fitness to practice
medicine is an egregious mistake. Implementing it in such a manner would be
catastrophic.
Over the past year, we’ve taken two parallel paths to
correct this error.
The first is legislative – change the law itself, either by
repeal or significant revision.
We felt we had made a lot of progress a few months ago, when
the House passed good language in the mid-year supplemental state budget. But
the Senate didn’t go along, and it died in conference committee.
The House added the same language to its budget proposal for
next year, and we’re working hard to promote its passage.
The second approach is through regulation – and we have some
good news to report on that front.
After many months of discussions with the Board of
Registration in Medicine, the Board has proposed an interpretation that does
almost everything we could hope for.
It introduces a long list of waivers and exemptions that
would allow the overwhelming majority of currently licensed physicians to
continue practicing.
For a very small group of physicians, there would be a
requirement to complete 3 hours of CME, but nothing more.
The board also seems to make this a one-time requirement,
which means that you would not be required recertify yourself every time you’re
up for renewal.
The regulatory process is going to consume at least a few
more months. This includes a public comment period, where we will invite all
physicians to submit written comments. A strong physician turnout is essential
to ensuring that good regulations are promulgated.
I’m sure you’ve followed the stories about the controversial
selection process for medical marijuana dispensaries in the state.
While we haven’t commented publicly about the dispensaries –
and don’t plan to – we’re quite interested in the medical marijuana
certification that’s already being done by physicians during the early stages
of the implementation of the law.
No dispensaries are open yet, but several physicians have
already opened new practices that are solely focused on providing patients with
medical marijuana certifications. They have certified well in excess of 1,000
patients. While it’s legal to certify patients at this point, we do have some
significant concerns.
The first concern is that these physicians may not be
providing their certifications in the context of a bona fide patient-physician
relationship, as the regulations require.
While some may be evaluating the patient’s complete medical
record, they are doing so with the expressed intent of writing a marijuana
certification, and receiving a fee from the patient for doing so.
This is not consistent with the accepted practice of
medicine. I could not – for example – open a clinic just to prescribe oxycodone
or Percocet.
However, I could open a pain clinic where multiple treatment
modalities are available, including oxycodone and Percocet. There’s not a big
leap from the practice with a single-treatment focus to the “pill mills” that
we see here and there around the U.S.
In other states, a small number of physicians have certified
a very large number of patients.
You’d like to think that this couldn’t happen in
Massachusetts … but how could we be sure? Can we afford to be complacent?
There are a few other issues – such as the slow pace of
registering these certifications to the database of the Prescription Monitoring
Program.
When made operational, it will be easier to hold outliers
among physicians accountable for their actions.
Improving the PMP becomes even more important, in light of
the Legislature’s efforts to address the increased number of opioid abuse cases
in the Commonwealth.
We had a very productive meeting with the Board of Medicine
and the Department of Public Health to discuss the issue of “sole purpose”
marijuana certification practices.
There were some constructive recommendations regulating
these so-called “clinics.” We also discussed some good ideas about patient and
physician education.
To that end, we are holding a CME program on June 18th on
the clinical aspects of medical marijuana.
The aim is to create a system that would make medical
marijuana safely available in compliance with the law, while treating it in the
same manner as we deal with other controlled substances.
Last fall we launched an initiative to better inform
physicians and their groups regarding ACO’s and Clinical Integration. We had
the help of excellent consultants in preparing manuals on the subject.
Our team traveling around the state in an effort to clarify
what clinical integration is, and outline how physicians can maximize their
input in the governance and management of ACO’s.
These are some of the ways we have been working on your
behalf for the past year. If this were easy, anybody could do it. But it’s not.
It takes persistence, focus, and dedication.
Thankfully, we have all of these in abundance. With your
help, we will continue to make a difference on behalf of physicians and
patients throughout this great Commonwealth.
Me. Speaker, this concludes my report.
