Worcester District Medical Society

Worcester Medicine
January/February 2009

President's Message
By Bruce Karlin, MD

Editorial
View from the Top
By Paul Steen, MD

Worcester Medicine: View from the Top
University of Massachusetts Medical School: Meeting the Health Care Workforce Needs of the Future
By Terry Flotte, MD

Vision for the Future
By Michael F. Collins, MD

Medicine in Central MA - Our View at Fallon Clinic
By Jack M. Dutzar, MD

Safety, Transparency and Collaboration
By Octavio J. Diaz, MD, MPH

Communication & Efficiency
By Dale Magee, MD, MS

Legal Consult
The Road to National Health Reform - Eight Signposts Along the Way
By Peter Martin, Esquire

Science Corner
Community Collaboration for the Prevention and Treatment of Diabetes in Worcester
By Matthew Silva, PharmD, RPh, BCPS

Financial Advice for Physicians
Retirement Portfolio Protection - The Case for Long-Term Care Insurance
By Henrick Larsen, MBA, CLTC

Off Call
Music and Medicine at Mechanics Hall
By Joel Popkin, MD

President's Message
By Bruce Karlin, MD

I have had a long interest in Quality Assurance, having co-founded a company devoted to quality assurance in medicine and working there for 11 years. I returned to clinical medicine when it seemed that our vision of proper quality assurance would not happen. The problem was political, not technical. Now we at the District Medical Society are making headway with the political process of implementing helpful, non-punitive quality assurance.

The first step in quality control, according to Juran’s classic Quality Control Handbook, is to choose a control subject -- that characteristic (quality) we should standardize (control) to improve a product or service. HEDIS measures hardly pass muster as pivotal control subjects; rather, they are measurable surrogates for larger issues. Thus, tetanus shots stand in for immunizations, mammograms stand in for screening. When reviewed, most physicians are struck by the inaccuracy of the data compiled on our patients. The problem comes at this juncture: rather than review results to conclude that the data is poor, insurers initiate actions based on the presumed correctness of their measurements.

On the other hand, we conclude that the problem is the lack of standardized measurements and a lack of standardized communications. The fact that I cannot share records securely and quickly with other health providers is a subject worthy of the quality control discipline. We did not have to study whether the communication was not standardized, we knew it was not. So your leadership has set out to standardize those communications in our city.

This is why we started developed the secure e mail project with Central Massachusetts Independent Physicians’ Association, Fallon Clinic, Fallon Community Health plan, St. Vincent Hospital, and UMass Memorial Health Care. IT representatives from each of these organizations have worked diligently over the last 18 months to develop this system. We hope to go live the first of the year. Our community will benefit from their efforts. When operational, the system will allow physicians from disparate institutions to share patient information quickly and confidentially.

Once communications are secure, we can begin to create tools that can accurately measure immunization and screening. Indeed, the District Medical Society has joined with the Medical School to discuss a vaccine registry. Standardizing all records might be more of a challenge, but we come closer when all the Information Officers communicate regularly and all the Officers see the value of a common platform.

Our attention to the proper choice of quality control subjects makes our district the leader in quality improvement. Stay tuned.

Editorial: View from the Top
By Paul Steen, MD

This issue’s theme is Worcester Medicine’s view from the top. How do our local healthcare leaders see our medical future, taking into consideration both risks and opportunities? The main concerns of all the articles centers on healthcare delivery from the author’s institutional viewpoint: large integrated practice, smaller distributed care, traditional care and academic concerns. How are all of these models going to be impacted by the current national economic crisis? Is healthcare recession-proof? Lingering in the background is the ‘Massachusetts Experiment’ of universal healthcare. How will it impact each of the models and the individual physician’s workload?

One view in particular, Jack Dutzar of Fallon, is interesting in that he has fairly recently moved to Worcester giving him a unique view of our market. His view of opportunities and challenges facing us is not influenced by local bias. He offers a good view of reimbursement issues and his opinion on how they will play out. Terry Flotte of University of Massachusetts talks about academic issues of medical student enrollment and curriculum. He goes on to discuss the new CCTS (Center for Clinical and Translational Science) and its impact on the future of clinical research. Michael Collins’ article, also from the University of Massachusetts, talks about their plans for ATC (Advanced Therapeutics Cluster) that will supply cutting-edge disease treatments. The article from Dale Magee for CMIPA also concentrates on delivery of care with a concern on the absence of evidence-based guidelines and lack of connectivity between providers leading to fragmented care. He talks about a possible model that will lead to collaboration and connectivity, both vital steps for the future. Finally, Dr. Diaz from Saint Vincent Hospital focused on patient safety issues and the impact it has had on the medical community.

These are a sampling of the views expressed in this issue. When you read them understand them from the institution they represent. In many ways they share similar goals of better healthcare delivery but biased by their institution’s model of provider organization. The future will lie in what they have in common but will require compromises for a practical solution for the future. Considering our expectations for change coming out of the recent presidential election, will there be the same spirit of cooperation in healthcare?

University of Massachusetts Medical School: Meeting the Health Care Workforce Needs of the Future
By Terry Flotte, MD

As our population ages, the demand for health care will also rise at an ever-increasing rate. The Association of American Medical College (AAMC) reported in 2006 that the shortage of physicians in the US would reach 124,400 by 2025. Based on that data, the AAMC recommended a 30% increase in enrollment in US medical schools. This year, they updated their projections and now indicate that the figure is more likely to be closer to 160,000, despite all efforts to expand training and increase productivity.

As the state’s public medical school, the University of Massachusetts Medical School is committed to responding to the physician workforce needs of the Commonwealth. Our entering class of 2008 was the largest ever, at 114 students, and we anticipate the enrollment of 125 in the summer of 2009. Fortuitously, this change comes just as we have engaged in comprehensive competency-based curriculum reform, designed to anticipate the evolving role of physicians as leaders of the health care teams of the future.

In parallel with enrollment expansion and curricular reform, we have redirected our research emphasis towards the needs of patients. We created the Center for Clinical and Translational Science (CCTS) to provide a set of core services for clinical researchers. The CCTS takes advantage of our numerous interlocking networks of care across central New England, including the UMassMemorial Health Care system, the 5-campus University of Massachusetts system, Commonwealth Medicine, and Meyers Primary Care Initiative. The UMMS-CCTS is the centerpiece of our application to NIH for a Clinical and Translational Science Award. With this award, we hope to become one of 60 universities nationwide funded to bring the latest science to bear on the multiple health needs of our population. The National Children’s Study, led by Dr. Marianne Felice, UMMS Chair of Pediatrics, represents a similarly ambitious project that should open up tremendous opportunities to understand the root causes of poor health throughout life.

In all of these areas, we continue our collaboration with community physicians throughout the region. Our part-time and volunteer faculty partner with us in the care of over 1 million residents of central New England and will be called upon to share more fully in the school’s mission as the expanded classes of students enter their clinical years and as community-based research grows. We also remain dedicated to partnering on community service projects like the joint WDMS-UMMS initiative to establish a central vaccine registry for our county. By working together, we remain convinced we can meet the health needs of our population in these challenging times.

Terry Flotte, MD, is Dean, Provost and Executive Deputy Chancellor of the University of Massachusetts Medical School.

Vision for the Future
By Michael F. Collins, M.D.

Today in medicine, tremendous opportunities and great challenges are before us. Translational medicine — moving basic science discoveries from the lab bench into viable treatments delivered at the patient’s bedside and disseminated to the community — holds the key to enabling new ways of thinking about disease and, more importantly, new ways of treating disease. At the same time, however, demands on physicians to improve medical care, process large amounts of information and medical knowledge and provide answers to complex questions have increased while professional responsibility grows. Such an environment has created a new sense of urgency: how do we take advantage of the life sciences moment in Massachusetts, and use it as a catalyst for change?

At the University of Massachusetts Medical School, we are actively planning for a $449 million facility that will house the Advanced Therapeutics Cluster (ATC), which, we believe will provide the Worcester medical community with cutting-edge insights and strategies for treating disease. The new facility, the Albert Sherman Center, scheduled to open in 2012, will provide state-of-the-art research space for the ATC’s three new integrated research programs: a Gene Therapy Center, the RNA-interference (RNAi) Therapeutics Institute, and the Center for Stem Cell Biology and Regenerative Medicine. These three elements possess different but complementary capabilities for targeting underlying causes of disease and will capitalize on the achievements of biomedical investigators like our new Chair of Neurology, Robert Brown, Jr., M.D., D.Phil, one of the world’s leading researchers in ALS, and Victor R. Ambros, Ph.D., Professor of Molecular Medicine and co-recipient of this year’s Lasker Prize for Basic Medical Research.

Planning for the ATC fits within a larger framework of a new strategic plan for the medical school that sets a course for the next phase of our growth and development over the coming five years. This strategic plan, developed jointly with our clinical partner, UMass Memorial Health Care, crosses historic borders to bring together the entire academic health sciences center -- comprised of the school and clinical system -- basic science and clinical departments, and educators and investigators. Through this plan, specifically we aim to:

Achieve excellence in the practice of safe, high-quality care
Design and implement innovative educational methods to train clinicians, educators and scientists who will become the next generation of outstanding leaders in health care, as we meet the future health care workforce needs in Massachusetts and the United States
Develop and capitalize on the strengths of all staff who provide the operational support for our academic health sciences center
Nurture ongoing progress in the basic sciences to fuel breakthrough discoveries that will transform the practice of medicine
Translate scientific discoveries to improve patient outcomes and address the root causes of poor health

In each of these objectives, we will be guided by our commitment to collaborate closely with UMass Memorial Health Care and our other clinical partners. Together, we share a responsibility to the region to be a health care provider of choice, a partner in the training and education of health care professionals, and an active and engaged member of the communities we serve.

Over the Medical Cchool’s history, we have developed many diverse and unique resources that help change lives beyond our core role as an educator of tomorrow’s physicians, nurses and research scientists. Our strategic plan leverages those resources, from those that establish a pipeline for entry into the health professions to those that help providers and the commonwealth improve access to care for underserved populations by providing a safety net and improving quality, safety and effectiveness while serving those in need. By marshalling our resources, the University of Massachusetts Medical School, as an educational institution of distinction, will continue to shape globally the health care environment of tomorrow.

Dr. Collins is Chancellor of the University of Massachusetts Medical School and Senior Vice President for the Health Sciences for the University of Massachusetts system.

Medicine in Central Mass ~ Our View at Fallon Clinic
By Jack Dutzar, MD

It’s hard to underestimate both the opportunities and the challenges facing integrated, multi-specialty group practices in our world. Coming from across the country into this market has given me a view of the unique nature of Massachusetts, including the history and the policies that drive the healthcare industry and the choices we make.

On the opportunity side, the Commonwealth has given us tremendous potential by taking the risk of moving dramatically towards universal coverage. Also, this is still a fairly strong managed care market — one of the few left in the country. Overall reimbursement for services is higher than in other markets, and the inherent quality of and standards for healthcare services are very high.

The challenges are just as dramatic. The current economic crisis will affect us all in ways we haven’t yet begun to appreciate. In addition, the pain of transitioning from a paper world to an electronic one, including the associated implications for our work, and the growing needs of our patients are issues with which we are still struggling. We all agree that the workload is increasing and that patients, payors and regulators are expecting more from us than it sometimes seems we can deliver on. Personal physicians feel these issues most acutely as they find themselves on a perpetual treadmill in practices that are increasingly limited to high volume, office-based and RVU-driven patient care activities. And the dark specter of professional liability is never too far from the consciousness of many physicians.

In my work, I am inspired by the environment and what I believe we can accomplish. Our electronic health record is an amazing tool for supporting consistent use of evidence-based interventions in patient care, as well as for allowing much more effective communication among health professionals. We also have the resources and the will to utilize a broader range of professional disciplines and providers than is possible in a less integrated system.

There are two fundamental issues where the future looks especially opaque. The most immediate is the resolution of how best to pay for healthcare services. My own view is that fee-for-service (FFS) is likely not a model that is sustainable for the long-term. Yes, there is something fundamentally attractive to physicians about getting direct recognition of their work effort in that model, and FFS certainly inspires effort like nothing else can, but despite the positives, FFS is typically and fundamentally far more expensive than prepayment in whatever form. The financial issues for CMS in the next 15-20 years as the “Boomers” enter their high needs years are ones for which no one has any solution. The costs will likely dwarf any other entitlement, including Social Security. In our own commonwealth, the anticipated costs of providing broader coverage to our citizens are already an abandoned hope. We at Fallon Clinic are working hard to prepare ourselves for a world in which we will be paid for outcomes, global episodes of care and, yes, the continuing use of capitation.

The other big unknown is how we will resolve the issues of adult “primary care.” All of the policy wonks seem to agree on the importance of the role. The Medical Home model, with a personal physician at the helm, is on everyone’s lips, but without a clear view of how it will work. Fewer and fewer medical school graduates aspire to the role, and the distance between generalists and consultant specialty roles continues to grow in personal income, lifestyle and professional recognition. We simply cannot reconcile that trend with the view that patients organizing their own healthcare among various sub-specialists results in worse quality, lost opportunities and much, much higher costs.

At Fallon Clinic we are not immune to the drivers of reimbursement and other current realities, but we need very much to change the paradigm and create the best place to be a personal physician in America. We are most definitely a long way from there. We do have thoughtful people working on achieving that goal every day. One small example is a recent investment we are making into creating support for, and more opportunity for, our physicians to teach. There is a huge public and academic policy issue, however, as creating a great environment is not going to help if there are simply no skilled physicians who want the job.

The reconciliation of these issues into a sustainable and professionally satisfying future will, in my view, require that we “let go” of many of our traditional approaches to caring for patients and look for new ways of organizing care and meeting people’s needs. This will likely be a transition marked by uncertainty and some false starts. Our group will succeed or fail on our willingness to innovate and focus resolutely on decreasing waste and inefficiency as we hold ourselves accountable to the needs of our patients. Our ultimate strength is that our physicians are prepared to lead Fallon Clinic into that new world.

Jack M. Dutzar, MD, is President & CEO of Fallon Clinic

Safety, Transparency and Collaboration
By Octavio J. Diaz, MD, MPH

No one will argue that the last several years have brought about significant changes in the way we deliver healthcare. The staggering numbers of uninsured patients, mandatory caps on resident work hours, decreasing numbers of primary care providers and an aging population with increased healthcare needs have placed considerable strain on an already stressed system. And Worcester, like most large metropolitan areas, has not been spared. But the last few years have also ushered in a tidal wave of new regulations, mandates and requirements in patient safety and transparency that affects providers of healthcare services, from the independent physician to complex medical centers alike. And it is this focus on patient safety and transparency that is helping to shape the future of healthcare nationwide and right here in Worcester County.

Although safety in the delivery of medical services is not a new concept, recent changes in the way we understand and, more importantly, report our safety track record, has placed increasing workload on our region’s hospital quality and risk managers. Thousands of hours annually are spent reviewing events that may represent a safety concern in patient care. Fortunately, industry-wide, this unreimbursed time is recognized as money well spent for all the right reasons.

With patient safety squarely in the forefront of most healthcare regulatory agencies, transparency in reporting is not only recommended, it is a mandate that, if unanswered, will be met with the harshest of penalties. From a hospital’s perspective, unbiased and factual accounts of any patient safety concerns must be reported to agencies such as the Massachusetts Department of Public Health, the Board of Registration in Medicine, and The Joint Commission. Most of these reports become public documents, easily accessible in today’s lightning-fast information age. But with reporting transparency comes publicity and market share liability. Healthcare consumers have been given increasing access to understand our healthcare system’s ability to safely provide patient services, and to choose their providers based on factual information. On-line, consumers can research a hospital’s compliance with “core measure” performance, essentially an appraisal of the hospital’s ability to deliver quality care according to scientifically researched best practice models.

And this fall, adding to the importance of safety in the delivery of patient care, the Centers for Medicare and Medicaid Services (CMS) began denying payment to hospitals for charges incurred from certain complications related to the delivery of healthcare. Based on evidence-based models, CMS has begun denying payment for several conditions found to be preventable. In addition, CMS’s work on pay-for-performance continues, and will shape the way hospitals, physicians and other health care delivery agencies are paid for their services.

Individual practitioners and physician practices are affected as well. The patient, our healthcare consumer-now-customer, may be directed to physicians profiled or tiered and branded as more economical or more efficient. The patient receives deductions on their share of the cost of the encounter, and the practitioner is left to wonder what criteria were used to categorize his or her ability to deliver care.

Today, healthcare is adapting to the changes in the economy. Simultaneously, information regarding practitioner and hospital performance is being easily obtained and exchanged with frequency. Consumers are being asked to provide a larger share of the up-front cost at a time when it is progressively more difficult. So today, as the focus on patient safety and transparency becomes more evident, it is up to us to understand the science behind the acquisition of data, to assure its accuracy, and to educate our colleagues and patients accordingly.

As we strive to maximize our share of the shrinking healthcare dollar, safety and transparency in the delivery of healthcare has become an important part of our everyday life, partly because of new mandates and regulations and partly because of reimbursement limits imposed by CMS and other agencies. Physicians, hospitals and healthcare systems are aligned to work together to ensure the delivery of safe, efficient and cost-effective healthcare, and are now under the watchful eye of the consumer.

Octavio J. Diaz, MD, MPH, is Chief Medical Officer and Director of Medical Education, Saint Vincent Hospital

Communication & Efficiency
By Dale Magee, MD, MS

The crisis in health care today is not a crisis in the discovery of new cures; it is a crisis in how we deliver what we already know, in how we choose among the options that we have. Health care delivery needs to innovate, and innovation needs to occur in an environment in which new choices are continually being offered and the needs of the population are evolving. This requires agility on the part of those delivering care. Our vast web of health care providers remains so poorly connected that we have become accustomed to providing care for patients with missing information. These omissions can lead to poor quality, higher cost and lower safety.

For the past generation, the model that has been promoted is a variant of the nineteenth century industrial model with a vision of large integrated systems, usually occupying the same real estate, and top down management with efficiently organized “providers” working off of guidelines that reflect the most recent evidence. Nearly everything necessary for a patient’s care would be owned by the entity. Lives would be “captured.” Care would be coordinated, maximal efficiency would be delivered.

Present day reality does not realize this ideal, and for good reason. Solid evidence-based guidelines are not available for much of what patients need care for, and when guidelines are available, they often need to be modified to accommodate individual complexities. Fortunately, health care also differs from the factory model in that the most educated members of the team are out on the floor delivering care. This does not lend itself to top down management.

Today’s health care environment is offering an opportunity to small practices. Small offices can provide services with less overhead (estimated to be ~15% less per the Medical Group Management Association). The key to success is to increase the amount of patient management and decrease the number of managers -- especially those running the business of medicine. This not only requires widespread adoption of information technology but also the development of standards, cooperation among institutions that today are competitors and, most importantly, the commitment of all those caring for patients to assure the free flow of information and the closing of all loops in patient care.

This scenario is not all that unique in a society that has moved from an industrial model to a knowledge- based model. Thomas Friedman describes in “The World is Flat” innovation and efficiency being realized by our taking advantage of computers, software that tracks workflow, and connectivity via the internet that brings widely dispersed organizations together in a manner that fosters efficiency while enabling rapid adaptation to changing conditions. Thus, companies can thrive with much smaller infrastructures and products can be produced with dispersed suppliers (in our case, health care providers). Everyone is more able to innovate or readjust as the need arises. The key to dispersed assembly is communication and co-ordination.

Central Massachusetts Independent Physicians’ Association is making progress with just such collaboration and connectivity to provide choice, quality, convenience and cost-effectiveness. By integrating the care of patients while preserving the small offices in which physicians take personal pride in overseeing the details of health care delivery, we aim to bring the flexibility that is necessary to adapt and excel.

Dale Magee, MD, MS is a member of the Central Massachusetts Independent Physicians’ Association and is the Immediate Past President of the Massachusetts Medical Society.

Legal Consult: The Road to National Health Reform - Eight Signposts Along the Way
By Peter Martin, Esquire

The future of health care in Worcester and beyond will look a lot like the past if national efforts at health care “reform” are modeled on Massachusetts’s Chapter 58. A lengthy proposal sponsored by U.S. Senator Max Baucus (D-Mont.) is a leading candidate for shaping the national debate on health care reform. A look at that proposal reveals a number of concepts that will be familiar to Massachusetts observers of health care policy developments, as well as a few other ideas that have been part of the health care reform discussion. Below is a lexicon drawn from the “Baucus Plan” of ideas we will be hearing a great deal about nationally, as health care reform moves to Washington, D.C. with the new administration.

(1) Health Insurance Exchange. The “Baucus Plan” would create a national health insurance “marketplace” where individuals and employers can compare plans offered by private insurers that must meet certain coverage requirements. Sound familiar? Baucus specifically refers to the Commonwealth Connector when describing the Exchange.

(2) Individual Mandate. The proposal describes the need to increase the size of the insurance pool to avoid adverse selection and the effect on health insurance premiums of the uninsured utilizing emergency rooms, thus increasing premium costs for all consumers. The solution is an individual mandate, possibly enforced through the tax system. Again, Massachusetts’ example is cited.

(3) “Pay or Play.” The plan calls for employers which choose not to offer their employees health insurance to pay a percentage of their payroll into a fund to help cover the uninsured. This sounds quite a bit like the “Fair Share Contribution” that was recently revised in Massachusetts.

(4) “Independent Health Coverage Council.” This new group would determine the affordability of health insurance plans offered through the Health Insurance Exchange, perhaps based on a reasonable percentage of income. This group would also set standards for chronic care management and quality reporting. This role is played in Massachusetts by the “Health Care Quality and Cost Council.”

(5) “Medical Home Model.” Payment of providers for comprehensive care management is intended to increase quality and reduce costs. An alternative for rural areas is a “community health team” which would include nurses, nutritionists and social and mental health workers.

(6) “Episode Groupers.” This is a method of evaluating resource uses by providers, based upon the activities of all providers caring for a patient during a particular episode of illness. The hope is that evaluation of data in this way will identify “inappropriate care patterns.” It is one of several methods proposed in the Baucus Plan oriented toward refocusing payment incentives toward quality and developing a national system for performance measurement and reporting.

(7) “Accountable Care Organizations.” Another value-based purchasing concept is to make incentive payments to integrated delivery systems that meet certain quality measures. The incentive payments would represent recoupment by the group of a percentage of cost reductions realized by Medicare. Accountable Care Organizations could include hospitals and their employed medical staff, multispecialty group practices, PHOs and IPAs.

(8) “Charter Value Exchanges.” As with Massachusetts health reform, the Baucus Plan places emphasis on cost and quality transparency. Obtaining a sufficient amount of valid data has been difficult. The Baucus Plan proposes these “Charter Value Exchanges,” currently initiated by HHS in various communities, as a way for private holders of clinicians’ care data to combine that data with similar Medicare information. The goal is to allow a community to gain the benefit of a larger set of such data in order to create realistic cost and quality measures for that community.

What the Baucus Plan doesn’t do at present is to deal effectively with a number of issues that have arisen in Massachusetts since the advent of health care reform. The continuing shortage of primary care providers is mentioned but not much is proposed other than reviewing GME payments in the areas of primary care, geriatrics and preventive services. The plan cites health IT as a means of reducing costs and improving quality, but offers nothing innovative in easing the provider community’s transition to a fully electronic environment. The plan describes the conflict between the savings possible through gainsharing programs on the one hand, and the legal restrictions of the anti-kickback and self-referral statutes that impede such programs on the other hand, but does not resolve the dilemma. In this way, too, national health care reform may very well resemble Massachusetts’ experience writ large.

Science Corner: Community Collaboration for the Prevention and Treatment of Diabetes in Worcester
By Matthew Silva, PharmD, RPh, BCPS

The national economic climate makes discussion about managing local health care costs sometimes uncomfortable and inconvenient. One especially difficult reality has been that insurers and incentive systems have historically reimbursed health systems at a higher rate for aggressively treating acute disease rather than aggressively preventing acute disease by preventing chronic disease over the long term. This fact, along with the staggering increase in chronic disease burden from diabetes and cardiovascular disease, will make chronic and preventable diseases among the most costly items in the US health-spending budgets. We can preface the word “items” with the terms “direct cost” -- referring to the cost of medical expenses paid by patients and health systems -- and “indirect cost” -- referring to the cost of time and wages lost because of disease or illness. Let’s consider the relative impact of diabetes in Worcester alone. Estimates of the disease’s cost locally are at $403.8 million, with $280.4 million in direct costs and $123.4 million in indirect costs [Dall 2008].

Now we can consider national projections from a recent report Figure 1: 2007 Updated Medical spending on all forms of Diabetes: $218 billion (NCDP/Lewin Group)

Type 1 and Type 2 DM
Among patients requiring insulin treatment (the minority of patients who used to be called Type 1 DM), approximately 1 million patients -- or 5.7% of the 17.5 million with diabetes -- accounted for 14.9 billion (8.6%) of DM spending, including $10.5 billion in direct costs and $4.4 billion in indirect costs. Type 2 diabetes accounted for $159.5 billion (91.4%) of diabetes spending, with $105.7 billion in direct costs and $53.8 billion in indirect costs.

Undiagnosed diabetes
There were 6.3 million people with undiagnosed diabetes in 2007 at an economic cost of $18 billion -- $2,864 per person with undiagnosed diabetes and with direct costs of $11 billion and indirect costs of $7 billion..

Pre-diabetes
57 million patients were thought to have pre-diabetes in 2007 (nearly 3 times more patients than those with currently diagnosed and known diabetes) and carry a high risk of progressing to Type 2 diabetes during their lifetime. Annual medical costs for this risk group are >$25 billion ($443 per person) with pre-diabetes due to increased use of medical services for other problems and frequent testing.

Gestational diabetes
Gestational diabetes occurs in 8.7% of pregnancies in women > 35 years of age; or 180,000 cases in 2007 which increased the cost of each pregnancy by $3,305. This represented direct medical costs of 636 million dollars in 2007 with 596 million spent in maternal costs and 40 million in neonatal costs. 230 million (36%) is covered by medical expenses; 355 (56%) million in private insurance and 51 million (8%) as self-paid, out of pocket costs or charity care.

Cost drivers
Costs of care are compounded by the need for more frequent visits and treatment for acute and chronic complications of diabetes, intensification of treatment, management of multiple risk factors, and management of co-morbidities including hypertension, metabolic, renal and endocrine complications beginning 2-4 years prior to diagnosis. Employers are currently covering 158 million people through health insurance plans, but increasing costs in our health systems result in greater employer, government, health-plan and patient contributions because all costs for all parties are increasing. This suggests the real solutions will come from true prevention. Prevention will mean delaying further complications and costs of care in patients with diagnosed disease and, in a larger sense, preventing those with pre-diabetes or lifetime risk factors for the development of diabetes and heart disease from having these diagnoses. The burdens to the patient and the system are not in the diagnostic label; rather, they are through the aggressive medical treatment required to treat and extend life once a given amount of damage is done.

Thinking nationally, acting locally
Creative, unconventional solutions to the ever growing diabetes problem should be considered at a time when the same old approach gets the same old results ~ namely, greater rates of service utilization and higher costs from testing, but relatively few changes in health outcomes or durably slowing disease progression. How can local providers exert control over costs here at home? One suggestion is to look outside of the walls of the clinic or institution by partnering local fitness centers and community organizations.

Prevention and partnership
There is an urgent need to focus energy and attention on screening, prevention, education and supportive care including self-management, depression screening and treatment and disease management programs. The upside is that the costs associated with screening, education, patient empowerment and self-management as part of a comprehensive disease management program have been previously shown to reduce costs [Sidorov], [Wagner]. Reduction of future costs will come through prevention and education aimed at curbing preventable disease rather than further investment in therapies designed to address treatment of acute disease. Part of the answer is simple, time-tested, well-understood in theory but under-applied in practice by patients and providers alike. Part of the answer is awareness of energy intake, meal composition, stress and personal self-management, individualized goal setting with frequent ~ if not daily ~ exercise with aerobic and resistance training components. The other part is imparting durable, lifelong, lasting motivation to patients so the notion of exercise as medicine becomes ingrained and a habitual component of daily living. To be sure, enabling and empowering patients will come from health system restructuring and training strategies designed to empower all health workers, from receptionists to interventionalists, imparting the same message of positive coaching and valuing longterm prevention strategies as profitable in the short and longterm. Training to do patient self-management, stress-management and awareness for all staff in a health care system to achieve certification-level credentialing will be associated with some cost in time and materials but is well spent as a measure of future cost avoidance. Prevention-based savings in the form of deferred costs from acute events need to be quantified at 10, 20 and 30 years and will be retrospective in nature and continuously evolving.

Local examples in collaboration
The Worcester community hosts a number of creative physicians, clinicians and senior leaders with a history of experience working on new models of patient empowerment and self-management for diabetes [Rosal] [Olendzki] [Carbone] [Candib]. An established partnership involving the YWCA/Family Health Center of Worcester along with University of Massachusetts Medical School and the Massachusetts College of Pharmacy and Allied Health Sciences has been providing free and now low-cost access to exercise by identifying patients with diabetes, obesity and depression, managing care with a chronic disease management team, and using an exercise prescription for evaluation and referral while subsidizing patient memberships to the YWCA Worcester. This program began 5 years ago and is lead by a physician champion (Dr. Candib), involves a group of disease management specialists (nursing, medical assistants, provider champions), senior administration leaders, patient advocates, patient champions, medical and pharmacy students who train in the new model and 2 fitness centers (YWCA and YMCA) whose administration and staff support and provide access to exercise. The group of activity and exercise champions in Family Medicine in the Worcester local community is an example of grassroots efforts aimed at prevention and management of disease using non-pharmacologic means which are both cost-effective compared to conventional pharmacologic therapy over the long haul and have extended physical, psychological and social benefits. The group has also created collaborative partnerships in education and community advocacy with future-minded objectives of reducing the real chronic, physical and fiscal burdens of unchecked chronic disease in the Worcester community. Grant funding through the Blue Cross and Blue Shield Foundation will allow further expansion into the community, facilitate involvement from other community organizations, and establish a self-sustaining support mechanism.

Local data
Over the last 4 years, the group has collected data that suggests acceptance among patients, providers and community organizations [Tables 1 & 2]. There were 1,134 patients (through April 2008) making 14,266 exercise visits to the local YWCA or YMCA. Of this group, 119 patients with confirmed diabetes (Type 2 and gestational diabetes) accounted for 3,225 visits. The average age of all exercisers was 38.7 years and the average age of those with diabetes was 48.5. The proportion of minority patients (African American or Latino) accessing exercising facilities was approximately 70%, suggesting the program is being accepted and used by patients who are most affected by diabetes in the Worcester community. Patients who made the most number of visits during the study period had the largest improvement in their diabetes, measured as a reduction in HbA1c (a 3-month average of long term blood glucose control where lower numbers are better, greater reductions are better, and the goal for patients with diabetes is 6.5-7% for most patients). Patients with ³ 24 visits had average Hba1c reductions of -1% compared to their baseline (p=0.016). There was an overall -0.6% reduction in HbA1c for all exercisers (p=0.011) that compares to the typical HbA1c reductions observed when a patient begins oral medication to reduce blood glucose (typically -0.5-1% HbA1c reductions). The difference is that HbA1c reductions can be preserved with weight loss, maintenance, and continued exercise whereas HbA1c’s begin to slowly increase after several years of therapy with oral medications due to continued diabetes progression.

Table 1

Table 2

Other groups have gone further to demonstrate that the individualized practice of self-management saves thousands in avoided medical costs [Wolf]. Membership packages at the local fitness centers begin as low as $10 dollars per month (as in the local YWCA with provider referral from the Family Health Center of Worcester). Drug co-pays for long term medications range from as little as $4.00 per generic prescription to $30 for monthly co-pays for branded, 3rd tier medications ~ while some are entirely uncovered, leaving patients to pay full price out of pocket. Patients with DM often have 3-4 chronic medications which may result in monthly prescription coverage costs several times greater than that of a monthly gym membership. With weight loss, improved blood pressure, lipid, depression and diabetes control, some medications may be eliminated, streamlining therapy and minimizing both patient cost and drug risks from poly-pharmacy (the presence of multiple medications which may have similar effects and similar, additive toxicity).

The reality is that physicians and providers can leverage control in their own practices by thinking nationally and acting locally, addressing their own practices and focusing energy and time developing self-management skills with their patients as a mechanism for preventing chronic disease and related expenses.

Physical and fiscal health begins at home, in the community, and by rethinking our local priorities. Systems are reconsidering the relative proportions of funding allocated for preventative care and are offering incentive structures for good evidence-based care that controls costs by focusing on prevention. Medical, nursing, pharmacy and allied health students of today are observing a paradigm shift from a reward structure favoring acute disease treatment to a reward structure favoring prevention and self- management under a new framework of collaboration, education and patient empowerment for better health. Our teaching and practice of today needs to be creative and collaborative ~ involving community leaders and community institutions that are accessible to patients ~ if we are to prevent new chronic disease and its impending financial consequences.

References:

Candib LM, Silva MA, Cashman SB, Ellstrom D, Mallett K. Creating open access to exercise for low-income patients through a community collaboration for quality improvement: if you build it, they will come. J Ambul Care Manage. 2008;31(2):142-150

Carbone ET, Rosal MC, Torres MI, Goins KV, Bermudez OI. Diabetes self-management: Perspectives of Latino patients and their health care providers. Patient Education and Counseling 2007;66:202-210.

Dall T, Edge-Mann S, Zhang Y, Martin J, Chen Y, Hogan P. Economic costs of diabetes in the U.S. in 2007. Diabetes Care. 2008;31:1-20

Olendzki BC, Ma Y, Hebert JR, Rosal MC, Pagoto SL, Merriam P, Ockene IS. Underreporting of energy intake and associated factors in a Latino population at risk of developing type 2 diabetes. J Am Diet Assoc. 2008 Jun;108(6):1003-8.

Rosal MC, Benjamin EM, Pekow PS, Lemon SC, von Goeler D. Opportunities and challenges for diabetes prevention at two community health centers. Diabetes Care 2008;31(2):247-254.

Rosal MC, Olendzki B, Reed GW, Gumieniak O, Scavron J, Ockene IS. Diabetes self-management among low-income Spanish-speaking patients: A pilot study. Annals of Behavioral Medicine 2005; 29(3):225-35.

Sidorov J, Shull, R, Tomcavage, J, Girolami, S, Lawton N, Harris, R. Does diabetes disease management save money and improve outcomes? Diabetes Care. 2002;25:684-689

The National Changing Diabetes Program. Study finds cost of diabetes in the United States to be 218 billion. Press Release, November 18th, 2008. Accessed online at: http://www.ncdp.com/downloads/pressReleases/NCDP Economic Barometer FINAL.pdf. 12/1/2008

Wagner, EH, Sandhu, N, Newton, KM, McCullough, DK, Ramsey, SD, Grothaus, LC Effect of improved glycemic control on health care costs and utilization. JAMA. 2001;285:182-189

Wolf AM, Siadaty M, Yaeger B, Conaway MR, Crowther JQ, Nadler JL, Bovbjerg VE. Effects of lifestyle intervention on health care costs: Improving Control with Activity and Nutrition (ICAN). J Am Diet Assoc. 2007;107(8):1365-1373.

Matthew Silva, PharmD, RPh, BCPS is an Associate Professor of Pharmacy Practice, Massachusetts College of Pharmacy and Health Sciences and Adjunct Assistant Professor of Family Medicine, Department of Family Medicine and Community Health, University of Massachusetts Medical School and a Clinical Pharmacy Faculty member at Family Health Center of Worcester. Email comments to: matt.silva@mcphs.edu

Financial Advice for Physicians: Retirement Portfolio Protection - The Case for Long-Term Care Insurance
By Henrik Larsen, MBA, CLTC

Risk vs. Consequences

We buy an awful lot of insurance during our lifetime. Some of it we don’t use and some of what we do use, we use to a lesser extent than the combined premiums paid. That being the case, why do we buy insurance? Is it because of the risk we face that the insurable event will happen? No. We buy insurance when the consequences associated with the insurable event are sufficiently severe.

This applies to many things we do in our daily lives. Nobody buys a lottery ticket because of the enormous odds of winning. People buy lottery tickets because of the potential of winning tens or hundreds of millions of dollars.

Insurance goes hand in hand with protection. So let’s take a look at some of the things we feel compelled to protect and the corresponding types of insurance:

                     • Car                              Auto Insurance
                     • House                          Home Owner’s Insurance
                     • Family                          Life Insurance
                     • Income                         Disability Insurance
                     • Wealth                         More Life Insurance
                     • Retirement Portfolio      ?

Most people insure all of the above except when it comes to the retirement portfolio. Granted, there are numerous tools we can use to maximize our returns and minimize our exposure to market declines. Tools such as dollar-cost averaging, portfolio rebalancing and lifestyle mutual funds are common topics of discussion between retirement investors and their advisors. However, all of those tools pertain to the contribution years. What about the distribution years?

The single biggest risk to a retirement portfolio is the owner’s (or owner’s spouse) need for long-term care. What are the consequences of this risk? The consequences can be severe. Currently, the annual cost of long-term care is between $35,000 and $125,000 depending on the type of care needed and where it is provided. These costs have traditionally increased by three to five percent per year and it is not uncommon for the need for long-term care can to last more than five years. Following this trend, it is not inconceivable for individual long-term care costs to exceed the $1 million mark within the next couple of decades.

Retirement Planning involves the Entire Family.

Many retirement investors have significant savings ~ both qualified and non-qualified ~ and may feel that should the need for long-term care arise, care can be paid for from those savings. Let’s look at a simple example: a qualified retirement portfolio of $2 million provides annual pre-tax retirement income of $100,000 to $160,000 (5-8%). Should the need for long-term care arise, premature invasion of principal becomes a reality and that was never the intent in the first place.

Finally, in putting the numbers aside, let me introduce to you to the three children of Mr. & Mrs. Recently Retired: Adam, Betty and Charlie. Adam is a successful business owner, Betty is a sole-proprietor with three children living in the same town as her parents, and Charlie didn’t make the best choices in life and is currently unemployed, living in Arizona. Irrespective of who provides the care or who provides the money for the care, sibling friction is almost inevitable. Should Mr. & Mrs. Recently Retired use their own funds, leaving less of an inheritance or legacy for their grandchildren, children and favorite charity? Should Adam step in and pay, thereby indirectly funding Charlie’s much-needed inheritance? Should Betty provide the care ~ as she lives the closest to her parents ~ but at the expense of her own family?

The discussion of long-term care and Long-Term Care insurance [LTCi] is an integral part of a comprehensive retirement plan and must involve proper consideration of the entire family’s circumstances. This coverage can provide peace of mind for the entire family.

In addition, there is potentially favorable tax treatment of LTCi premiums relative to other benefits for sole-proprietors, for partnerships, and for corporations. And, finally, when one considers the enormous pressure that the falling stock market and the declining economy have already put on retirement portfolios, it’s clear that it is more important than ever to include long-term care insurance as an integral part of retirement planning.

Henrik Larsen, MBA, CLTC is the Vice President, Marketing of Advanced Resources Marketing [ARM] a Boston-based national insurance benefits firm with an exclusive focus on long-term care insurance. ARM is endorsed by the Massachusetts Medical Society through its subsidiary, Physicians’ Insurance Agency of Massachusetts. Henrik can be reached at: hlarsen@armltc.com or 800.269.2622.

Off Call: Music and Medicine at Mechanics Hall
By Joel Popkin, MD

How long have parents soothed their crying babies with a song? How long has music’s calming effect been used to lower heart rate and blood pressure, decrease anxiety, and help depression? In more recent decades, music has been shown to treat neurological conditions such as Parkinson’s, Alzheimer’s, and strokes, with complex cerebral imaging now having explained many of the links between music and the brain.

It thus should come as no surprise that so many members of the medical field have such strong, innate bonds to music. And so came Saturday evening, November 15, 2008, when M. Steinert & Sons presented “Doctors in Concert” at Mechanics Hall.

While the performers varied in age from 17 to advanced AARP and their programs ranged from Mozart to Ellington, the performances were consistent – all were excellent. Who knew that these colleagues of ours collectively possess this level of musical talent?

The concert began with Dr. Joseph Savitt playing the Gershwin Preludes, a rhythmic challenge surpassed only by the technical demands of his second offering: Chopin’s Scherzo in Bb Minor. Dr. Mary Hawthorne’s powerful rendition of Barber’s majestic Knoxville Summer of 1915, originally for soprano and orchestra, was followed by Thankful. Her husband, pianist David A. Pihl, accompanied her expertly. The first part of the program ended with Dr. Ken Wolf’s technically and emotionally perfect Mozart Sonata in D Major.

After intermission, Dr. David Degrand swirled the classical atmosphere with his own striking jazz piano compositions in tribute to Duke Ellington. Dr. L. Rebecca Spanagel then returned us to 100 years ago with a poignant interpretation of Debussy’s La Fille aux Cheveaux de Lin (The Girl with the Flaxen Hair). La madame aux cheveaux de lin then accompanied her son Paul, first with Saint-Saёns’ The Swan for cello and piano, and then with Ralph Vaughn Williams’ Three Songs for Travelers for baritone and piano. The buzz from the audience voiced agreement that this youngest performer of the evening is on utterly firm footing for a career in the “Music” part of “Music and Medicine.” Dr. Junya Awata then sealed this lovely evening as unforgettable with three remarkable finger breaking works: Chopin’s Etude Op. 10 No.3, Ravel’s Jeux D’eau, and Rachmaninoff’s Prelude Op. 23, No.2.

Though all six doctors returned to their day jobs the next morning, the musical world has not been left hanging. Dr. Wolf walks the parallel universes of the neurosciences and music performance and composition. Dr. DeGrand actively records for CDBaby.com, and Dr. Spanagel accompanies her son at concerts in the Francis Parker Charter School. Dr. Savitt sings and leads services at the Beth Tikvah Synagogue in Westborough, where he also plays keyboard for the Klezmer band he founded. Dr. Awata performs at Steinert. In addition to performing concerts with her husband, Dr. Hawthorne is a member of the choir at Immaculate Conception Church in Worcester and a cantor at Holy Spirit Parish in Wells, Maine.

The Doctors’ Concert confirmed the powers of music and medicine. We hope that “Dr.” Bob Bates and M. Steinert & Sons will refill this “prescription” for years to come.