The $20 billion Congressional plan – which would also extend the payroll tax holiday and unemployment insurance benefits through the end of 2012 – would be paid for with public health funding from the federal Affordable Care Act and cuts to federal health-care and Medicaid spending, including programs for hospitals with bad debt, officials said.

A previous two-month delay to the Medicare cuts, hammered out in a dramatic year-end Congressional session, was set to expire March 1.

Late last month, the MMS, the AMA and 107 other state and specialty medical societies called on Congress to eliminate the payment formula permanently, and offsetting the costs with money budgeted, but not utilized, during the Iraq and Afghanistan wars.

MMS president Lynda Young said today she was frustrated that lawmakers did not come up with a permanent solution, and settled for yet another short-term patch.

“A true solution — a full and complete repeal of the Medicare payment formula – is long overdue,” said Dr. Young.  “We deeply appreciate the fact that the Massachusetts congressional delegation has supported reforming the payment formula and hope to work with them in the coming months to achieve this goal.”

AMA president Peter Carmel, MD, called the conferees’ action “a serious missed opportunity to permanently replace the flawed Medicare physician payment formula and protect access to care for military families and seniors.”

“People outside of Washington question the logic of spending nearly $20 billion to postpone one cut for a higher cut next year, while increasing the cost of a permanent solution by about another $25 billion,” Carmel said.

House Speaker John Boehner said he expects the tentative agreement could be voted on by the House and Senate by week’s end.

–Erica Noonan

The acting administrator of the Centers for Medicare and Medicaid Services said today  her agency may delay adoption of a complex new insurance coding system.

Speaking at a conference of the American Medical Association on Tuesday, Marilyn Tavenner (right) said CMS is considering giving the nation’s doctors more time to switch to the ICD-10 systems.  Currently, the law requires implementation by October 2013.

“I’m committing today to work with you to reexamine the pace at which we implement ICD-10,” Tavenner said to loud applause from hundreds of physicians. “I want to work together to ensure that we implement ICD-10 in a way that (meets its) goals while recognizing your concerns.”

Proponents say the switch from ICD-9 to ICD-10 will bring the U.S. medical system in line with much of the rest of the world, while allowing health officials to better track the nation’s health and monitor diseases.  The new system has some 68,000 codes, five times the amount under the current system.

The AMA and other physician groups say switching to ICD-10 coding will cost medical practices anywhere between $83,290 and more than $2.7 million, and that the pressure is too much while physicians are also coping with complex new electronic health record requirement mandates.

Lynda Young, M.D., president of the Massachusetts Medical Society, praised Tavenner’s openness to delaying ICD-10 implementation.

“This is a good thing, and it will give us more time to get ready,” said Dr. Young. “There are serious time and cost issues for practices trying to implement all of these changes at once.  We want to give people a chance to take care of the other changes first.”

Tavenner said her office would formally announce its intention to craft new regulations within the next few days.

More on the CMS announcement:

• “Medicare could delay burdensome rules on doctors,” The Hill (blog)
• “Feds may Delay ICD-10 Deadline,” Informationweek Healthcare

–Erica Noonan

The Massachusetts Senate’s recent unanimous passage of a bill to expand the state’s Prescription Monitoring Program is well intentioned, addresses a serious and growing problem, but, like The Boston Globe editorial of February 8 that speaks to the issue, falls short of addressing the heart of the matter.

Since 1992 when the PMP was established (with Massachusetts Medical Society support), the Department of Public Health has electronically recorded every prescription for Schedule II drugs, and since 2010, every Schedule III through V as well.  DPH has had regulatory and statutory mandates to review those prescriptions to find doctor shoppers and prescribers who overprescribe.

Its efforts, however, have fallen short, as no meaningful data, such as cross referencing Schedule II prescriptions with overdoses in the PMP database, has been compiled.  Prescribers are already registered with the DPH, yet are not given automatic access to the database, so additional registration by physicians would only seem redundant.  Further, prescribers are not notified of doctor shoppers among their patients with any frequency, another action that could reasonably be taken with an electronic system and an accurate read of the database.

An electronic database is a strong tool in the fight against prescription drug abuse, but the data must be accurate and timely. Real-time information, instead of that from the current lag of 10 days in pharmacies reporting to the DPH, is better.

Let’s also recognize that a major source of the prescription drugs being abused come from outside the state – a fact reported by the Cape Cod Times – and confirmed by law enforcement – in an eye-opening three-part series, “Pills that kill,” published in September of 2010.

We’re  keenly aware that “doctor shopping” is part of the problem, and that means that doctors can be part of the solution.  As prescribers, we are willing and eager to help. But it is not, as The Boston Globe suggests, “inconvenience”and “technophobia” that prevent us from enthusiastically backing the proposed legislation.

Before the state adds more administrative and costly steps, and before we take those steps that may risk delaying and denying appropriate care to patients who require it, let’s recognize that we have an adequate system in place. We should use it to its fullest capacity.

New: Read Dr. Young’s  Commentary on CommonWealthMagazine.org

This post was updated on February 15, 2012.

About 80 percent of adults with acute bronchitis receive a prescription for antibiotics, yet most bronchitis is due to viral infection for which antibiotic therapy offers no benefit.

The MMS is offering a collection of tools for physicians to make decisions about antibiotics and communicate effectively with their patients. These include bronchitis and sinusitis treatment algorithms, office posters and patient handouts.

To view and download the materials for free, visit www.massmed.org/antibiotics.

Thanks to the Massachusetts Department of Public Health, Massachusetts Association of Health Plans, the Massachusetts Hospital Association, Blue Cross Blue Shield of Massachusetts, the Partnership for Healthcare Excellence, Atrius Health, and the Reliant Medical Group for again participating in this effort.

• Communication and collaboration skills
• Peer review and management abilities
• Long-term goal setting and strategic planning
• An understanding of health care economics and data

That’s what more 50 physicians heard at the MMS this week, as they gathered to strengthen their skills in a subject rarely taught in medical school or residency: Leadership. It was the inaugural sessions of the MMS’ new Physician Leadership Institute.

“The reinvention of health care is just beginning,” MMS President Dr. Lynda Young told the attendees of the four-part series. “We want to teach more physicians the art, science and discipline of leadership.”

The first session, “Changing Paradigms in Healthcare; What Does the Future Hold?” included a overview of health care industry trends, as well as seminars on change management, generational differences among physicians, emerging roles for physician leaders, and coaching and mentoring skills.

The group will meet for two online sessions, before the final live module, “Evolving Roles for Physician Leaders in the Age of Healthcare  Reform,”  focusing on organizational transformation, goal-setting and problem-solving, and technology implementation, scheduled for September 14.

This week’s session was conducted by the California-based Institute for Medical Leadership, with training conducted by its president and CEO,  Susan Reynolds, M.D., and presentations from  Institute faculty members C. E. Mickey Bilbrey, former president and CEO of the University of Tennessee Medical Center,  and Richard Corlin, M.D., president of the AMA from 2001-2002.

Clinical integration, cooperation between health systems and hospitals, cost management, and quality measurement techniques will be vital to the future of the industry, so physicians must be the ones to lead patients, peers, administrators, payers, and elected officials in the right direction, Institute staff said.

“We have to have great physician-leaders to lead this process,” Bilbrey said. “You can’t sit on the sidelines.”

Reynolds described the evolving roles for physicians to lead in areas of quality and patient safety and information technology, including many executive positions that did not exist only a few years ago.

One of the biggest challenges for physician-leaders is abandoning traditional, dictatorial model of management in favor of the team-building, collaborative approach demanded by 21st century health care systems.

“The most successful physician leaders are going to be the one who close the gaps,” said Reynolds.

– Erica Noonan

The Massachusetts Medical Society shares your concern over high rates of opioid abuse in Massachusetts.  The Society works closely with the legislature and the Patrick administration to address the problem and frequently hosts events targeted at educating physicians regarding responsible prescribing habits, pain management, drug diversion and patient education.  Most recently, the MMS collaborated with the Board of Registration in Medicine to implement CME’s for physicians on pain management.  We are proud of our efforts to reduce prescription drug addiction and diversion, but realize more could, and should be done.

S.2122, “An Act Relative to Prescription Drug Diversion, Abuse and Addiction” is a good multi-pronged approach to the problem of prescription drug abuse.  The MMS supports language in the bill designed to increase the usefulness of the prescription monitoring program as a valuable clinical tool in prescription decisions.  We support the production and distribution of educational materials to inform and enlist consumers in actions that will protect their families from access to narcotics and help patients decide their treatment options.  We strongly support the provision of limited immunity from drug possession charges and prosecution when a drug related overdose victim or a witness to an overdose seeks medical attention.  The Society also looks forward to working with the Executive Office of Health and Human Services on a joint policy group to investigate best practices for reducing diversion, abuse and addiction.

However, the Society must register its concern regarding S.2122’s mandate that all prescribers enroll in the Prescription Drug Monitoring Program, some by next January, and utilize the program before prescribing any schedule II or schedule III drug.  While a very useful tool, the PDMP is still evolving and the MMS questions its ability to accommodate the needs of twenty thousand or so new practitioners in a timely and useful manner.  For some physicians, including those who may fall into the “high prescriber” category like emergency physicians, time is of the essence.  Primary care providers have a jam-packed schedule and checking with the program several times a day during a patient visit may extend waiting times for patients, extend clinical hours for overworked clinicians and distract providers from patient care issues unrelated to abuse.  What if the system is down, or unavailable?  Would the physician be prohibited from writing the necessary prescription?

First it is essential that the DPH has the capacity to develop good quality data on prescriptions and that the data is accurate and meaningful.  A phased-in registration process that begins with high volume prescribers of schedule II opioids is a reasonable approach which we support.  Mandating review of patient records in the PMP prior to an initial prescription for oxycontin is a reasonable approach to gain value from the PM P.

The legislation should require the DPH to make outreach efforts to all prescribers detailing the program’s benefits and making free and quick on-line registration for physicians available before mandates are initiated.  By working with Board of Registration, the DPH could issue secure passwords and registrations to all actively licensed providers with prescribing privileges in the Commonwealth.

Coming on the heels of last year’s mandate for pain management CME’s for all physicians who write prescriptions for any medication, the MMS would further suggest that the working group created in Section 18 of S.2122 should begin its investigation and study into best practices for reducing drug abuse, and that those recommendations be considered prior to any further legislative mandates or requirements.  One point for consideration is to remove mandates for pain management training for physicians who do not write prescriptions for opiates and other pain medications.

In conclusion, the MMS appreciates the efforts of Senator John Keenan and the Mental Health and Substance Abuse Committee and looks forward to continuing to work on revisions to S.2122 and other initiatives to reduce prescription drug abuse.

Sincerely,

Lynda M. Young, M.D., F.A.A.P.

Erin Tracy, M.D., M.P.H., (photo, right) Chair of the Massachusetts Section of the American Congress of Obstetrics and Gynecology and a physician at Massachusetts General Hospital, and Glenn Markenson, M.D., (center) Chief of Maternal Fetal Medicine at Baystate Medical Center in Springfield and Chair of the Western Massachusetts March of Dimes Committee, discuss aspects of pre-conception, pre-natal care, delivery, and post-natal care with host Lynda Young, M.D. (left), a Worcester pediatrician and MMS President.

The conversation includes the importance of a healthy lifestyle well before becoming pregnant, taking vitamins and staying current with vaccinations, regular check-ups and screenings, the timing of delivery, preparation for post-natal care, Caesarean sections, post-partum depression, and what parents should do when the “handoff” takes place from the obstetrician to the pediatrician.

Physician Focus, now in its eighth year of programming in 2012, is available for viewing on public access television stations throughout Massachusetts. To view online, visit www.physicianfocus.org. Physician Focus is also available on iTunes at www.massmed.org/itunes.

Pain management: Effective Feb. 1, physicians who prescribe controlled substances (Schedules I through VI) must complete at least three credits of education and training in pain management and opioid education.

MMS and the Boston University School of Medicine offer two courses to help physicians fulfill that requirement:

• Managing Risk When Prescribing Narcotic Painkillers for Patients
• Safe and Effective Opioid Prescribing for Chronic Pain

End-of-life care: Also effective Feb. 1, all physicians seeking a new or renewed license must take two CME credits in end of life care. The credits can qualify as either category 1 or category 2, and may be counted as risk management credits.

The MMS offers three online courses to fulfill this requirement:

• Legal Advisor: Advance Directives
• The Unintended Consequences of DNR
• The Importance of Discussing End-of-Life Care with Patients

The pain management education requirement was created by the Legislature in statute enacted in 2010. In public testimony, the MMS unsuccessfully opposed that requirement.

Mandatory education in end-of-life care was imposed by the Board of Registration in Medicine (BRM) following the recommendation of a special commission. It was not a legislative mandate, and the MMS opposed the inclusion of this condition for licensure based solely on the BRM’s perception of the significance of the issue.

BRM Executive Director Stancel Riley, MD, is scheduled to meet the MMS Board of Trustees in March to discuss these and other new licensing regulations.

It will require three hours of CME credits in pain management for physicians who prescribe controlled substances (Schedules I through VI). These credits qualify as either category 1 or category 2 CME, and may be counted as risk management credits. This requirement was established by the Legislature by statute in 2010.

The MMS recommends two courses to fulfill this requirement:

• Managing Risk When Prescribing Narcotic Painkillers for Patients
• Safe and Effective Opioid Prescribing for Chronic Pain

The Board will also require physicians to take two credits in education about end-of-life care, also effective Feb. 1.  The credits qualify as either category 1 or category 2, and may be counted as risk management credits. This is a requirement imposed by the Board very recently, following the recommendations of an expert panel on end of life care that met in 2008.

The MMS online CME center offers three courses that would fulfill this requirement:

• Legal Advisor: Advance Directives
• The Unintended Consequences of DNR
• The Importance of Discussing End-of-Life Care with Patients

The state’s complete CME requirements for licensure and re-licensure are available on the MMS website.

We encourage physicians to review this information immediately and contact each of the health plans if they have questions or want to appeal their tier designation.

The deadline to file an appeal of your designation is January 24. If you miss the deadline, you won’t be able to appeal for another year. The plans have said they will notify you of the outcome of your appeal by February 14.

Each health plan, in their communications to physicians, has provided information about who to contact and how to appeal. Keep track of your communications with each plan to make follow-up easier. We are also updating our website with this and additional information at www.massmed.org/tiering.